Inaccurate Medical Records and Documentation Errors Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by inaccurate medication diagnoses and documentation errors. For one resident, a physician's order for Apixaban incorrectly listed the diagnosis as pleural effusion instead of pulmonary embolism. Another resident was prescribed Escitalopram Oxalate (Lexapro) for dementia, although the medication was intended for anxiety, and the diagnosis listed in the order was not appropriate for the medication being administered. These discrepancies were confirmed by the Director of Nursing during interviews. Additionally, a review of psychiatric evaluation notes for a third resident revealed that the psychiatrist repeatedly referred to a female resident as a male in the documentation, despite the resident's correct gender being noted elsewhere in the record. These errors in resident-identifiable information and medical record documentation were identified during the survey process and confirmed by facility staff.