Incomplete Medical Records and Missing Documentation for Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by professional standards. Review of the closed medical record revealed that the resident, who had multiple diagnoses including type 2 diabetes, psychosis, severe malnutrition, and dementia with agitation, had several medication orders documented in the electronic Medication Administration Record (eMAR). However, on multiple occasions when medications such as lorazepam, mirtazapine, trazodone, and Ativan were held, there was no corresponding documentation in the Progress Notes by nursing staff explaining the reasons for holding the medications. Specific dates and times were identified where the eMAR indicated medications were not administered, but the required explanatory notes were missing. Additionally, the facility was unable to provide complete unit assignment records for certain dates and shifts, which the Director of Nursing (DON) confirmed were considered part of the residents' medical records. The DON acknowledged that the medical records should be complete and was unable to provide a policy regarding medical records when requested. The incomplete documentation and missing records were confirmed during interviews with the DON and the President of Clinical Services.