Failure to Maintain Accurate Medical Records for PICC Line, IV Antibiotics, and Insulin Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents in relation to PICC line dressing changes, intravenous antibiotic administration, and blood sugar assessment with insulin administration. For one resident with a peripherally inserted central catheter (PICC) line, the dressing was observed to be unchanged for an extended period, with the hand-labeled date on the dressing not matching the documentation in the Medication Administration Record (MAR). The nurse responsible confirmed that she had not performed the dressing change as documented, indicating an error in recordkeeping. Both the Administrator and Director of Nursing acknowledged that documentation should be accurate. For another resident receiving intravenous antibiotics, there were two instances where the MAR was not signed to indicate administration of the medication, despite nurses later confirming that the medication had been given but not documented. Similarly, a third resident with diabetes had multiple occurrences where blood sugar checks and insulin administration were not documented on the MAR. The nurses involved could not recall the reasons for the missing documentation. Interviews with the Physician's Assistant and Director of Nursing confirmed that medications and assessments should have been accurately documented as ordered.