Incomplete and Inaccurate Medical Record Documentation for Medications and Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents reviewed for medication, treatment, and wound administration. Specifically, there were multiple instances where Medication Administration Records (MAR), Treatment Administration Records (TAR), Wound Administration Records (WAR), and Controlled Drug Records were either incomplete, missing, or inaccurately documented. For example, one resident's records for Norco, Pregabalin, tramadol, and wound cleanse treatments were not properly completed or accurately reflected in the MAR, TAR, WAR, and Controlled Drug Records. Another resident's MAR for Lorazepam was missing for two consecutive months, and the documented dose did not match the Controlled Drug Record. A third resident's MAR and Controlled Drug Record for Hydrocodone showed discrepancies in the number of doses administered. Interviews with nursing staff, the DON, and other facility personnel revealed a lack of consistent procedures and understanding regarding documentation requirements. Staff reported that medication errors were not always documented or reported as required, and there was confusion about the retention and submission of narcotic logs, especially for discontinued medications and discharged residents. The DON and other staff acknowledged that documentation practices were not being followed correctly, and some staff expressed concerns about the accuracy and completeness of the records. Additionally, there were reports of medical record entries being removed or edited, further contributing to the lack of reliable documentation. The affected residents had significant medical needs, including pain management for conditions such as cellulitis, end-stage renal disease, morbid obesity, schizoaffective disorder, and dementia. Despite active orders for medications and treatments, the facility's failure to document administration accurately and completely meant there was no reliable record to confirm that residents received their prescribed care. The absence of proper documentation also extended to the facility's narcotic record logs, which were found to be disorganized and inconsistent, with multiple forms in use and missing records for some residents.