Failure to Maintain Accurate Medical Records and Medication Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation for two residents, resulting in deficiencies related to medical records and medication administration. For one resident with a diagnosis of depression, the medical diagnosis list did not include any depressive mood disorder, despite multiple physician progress notes and medication orders indicating treatment for depression and anxiety. The resident was prescribed sertraline for depression and alprazolam for anxiety, and both the primary and psychiatry doctor progress notes referenced depression as part of the resident's medical history. The Director of Nursing confirmed that the diagnosis list should have reflected a depressive mood disorder, as accurate documentation is necessary for staff to understand the resident's current condition and provide appropriate care. For another resident, the Medication Administration Record (MAR) for a specific month inaccurately indicated that the resident received a dose of Naloxone, a medication used to reverse opioid overdose, when in fact the medication was not administered. The order for Naloxone was present as needed for opioid overdose, but a registered nurse confirmed that the resident did not receive the medication and that its administration was mistakenly documented. The Director of Nursing acknowledged this as a documentation error and emphasized the importance of correct medication administration records to prevent errors in care. Both deficiencies were identified through observation, interview, and record review, and were found to be inconsistent with the facility's policy and procedures, which require medical records to be complete and accurate. The facility's own policies stress the need for standardized, legible, and descriptive documentation to ensure the highest quality and accuracy in resident care records.