Incomplete Medical Records and Informed Consent Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident with depressive disorder, dementia, and psychosis, the informed consent for a psychotropic medication did not document the method used to verify that the physician discussed the risks and benefits with the resident or their representative. Both the LVN and RN confirmed that the consent form was incomplete, as the section indicating how the consent was verified was left blank. The Director of Nursing also acknowledged that the consent was not complete due to missing documentation on the verification method. For another resident with depression, dementia, and anxiety disorder, the informed consent for a mood-stabilizing medication was also incomplete. The consent form lacked the date beside the physician's signature and did not indicate how the informed consent was verified by the licensed nurse. Both the LVN and RN identified these omissions during their review, and the DON confirmed that the consent was not complete because the physician's signature was not dated and the verification method was not documented. Additionally, for a resident with cerebral infarction, dementia, and a urinary tract infection, the administration of an antibiotic (Augmentin) was not documented in the Medication Administration Record (MAR) as having been given at the prescribed time. Although the Emergency Kit Pharmacy Log showed that the medication was administered, this was not reflected in the resident's MAR. The Infection Preventionist and DON both confirmed that the lack of documentation in the MAR resulted in inaccurate medical records, as it was unclear whether the resident received the medication as ordered.