Incomplete and Inaccurate Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was being treated for multiple complex conditions, including chronic pulmonary edema, end stage renal disease, and type 2 diabetes. On the day in question, the resident returned from dialysis and experienced hypotension, prompting the ADON to obtain a physician's order for Midodrine to address the low blood pressure. The ADON administered the medication but did not enter the order into the system herself, instead allowing a new LVN to input the order. The LVN, unfamiliar with the process, entered the order with an incorrect start date, causing the medication administration record (MAR) to reflect the wrong date for the Midodrine order. Additionally, the MAR was not signed by the ADON, who had administered the medication, leaving the documentation incomplete. The facility's policies require that the MAR be reviewed and signed after medication administration, and that all services provided be accurately and timely documented in the resident's medical record. Interviews with the ADON, DON, and LVN confirmed that the order was entered incorrectly and that the MAR was not signed as required. This resulted in an incomplete and inaccurate clinical record for the resident, as the documentation did not accurately reflect the medication administration or the timing of the physician's order.