Inaccurate Documentation of Antibiotic Use
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure accurate documentation in the medical record for one resident who was prescribed Cephalexin, an oral antibiotic, for community-acquired pneumonia. A review of the resident's physician's orders confirmed the ongoing antibiotic therapy, while progress notes over a period of several weeks contained ten entries by nursing staff incorrectly indicating that the resident was not currently on antibiotics. During an interview, the Assistant Director of Nursing confirmed that the resident was indeed on antibiotics and acknowledged the inaccuracy in the charting. The facility's policy requires that documentation in the medical record be objective and accurate.