Failure to Document Behavioral Incident and Medication Order Transcription Error
Penalty
Summary
The facility failed to document a behavioral incident involving a resident with a history of bipolar and delusional disorders. The incident occurred when the resident became agitated, was verbally aggressive, and struck the Human Resources Director, prompting law enforcement involvement. Multiple staff interviews confirmed that the event was not recorded in the resident's medical record, progress notes, or risk management forms, despite facility policy requiring documentation of significant changes in condition and behavioral incidents. The lack of documentation was acknowledged by the Assistant Director of Nursing, Director of Nursing, Unit Manager, and Administrator, all of whom stated that such incidents should be recorded to ensure proper monitoring and follow-up. Additionally, the facility failed to ensure accurate transcription of medication orders for another resident. A nurse transcribed a medication order for tranexamic acid onto a resident's Medication Administration Record (MAR) without verifying that the order was actually prescribed to that resident. The error occurred because the nurse did not check the name on the hospital discharge paperwork, resulting in a one-time dose of medication being recorded for the wrong individual. The Director of Nursing and Administrator confirmed that the transcription error was due to a failure to match the resident's name with the correct medication order from the hospital discharge summary.