Incomplete and Inaccurate Medication Administration Records
Penalty
Summary
Facility staff failed to maintain accurate and complete health records for two residents who were reviewed for medication administration. Both residents had complex medical conditions, including Type 2 diabetes, essential hypertension, end stage kidney disease, and dependence on dialysis. The review of physician orders and medication administration records revealed multiple instances where required documentation was missing or incomplete. For one resident, a medication for high blood pressure was omitted 17 times out of 62 opportunities, with the reason for omission often noted as 'other/hold - see progress notes,' but without corresponding documentation of vital signs in at least one instance. For the other resident, medication administration records were incomplete, with blank entries, missing documentation of blood pressure and heart rate during refusals, and an instance where medication was administered despite the resident's heart rate being below the ordered parameter. Additionally, insulin administration records were incomplete, with missing blood sugar values and unclear documentation of the number of units administered. During an interview, the DON confirmed that it is expected for all residents to receive medications as ordered and for records to be complete, including documentation of vital signs when medications are held. The DON also stated that physicians should be notified of any missed or refused medications. The lack of complete and accurate documentation in the residents' health records did not present a full and accurate account of their status and could result in missed changes in health.