Failure to Accurately Review and Update Resident Medication List in Progress Notes
Penalty
Summary
Medical providers failed to accurately review and update the total plan of care and medication list for a resident with atrial fibrillation and benign prostatic hyperplasia. The resident was admitted to the facility and had Eliquis, a blood thinner, discontinued prior to a suprapubic catheter placement as ordered by the nurse practitioner. Despite this discontinuation, subsequent nurse practitioner and physician progress notes repeatedly listed Eliquis as an active medication, with each note including a statement that the medication list had been reviewed and that the Medication Administration Record (MAR) should be referenced for an up-to-date list. Multiple progress notes over several weeks continued to include Eliquis on the medication list, even though the medication had not been restarted after the procedure. Addendum clinical clarifications were later electronically signed by the physician, stating that the resident was not taking Eliquis on the dates of the progress notes. Interviews with the nurse practitioner and physician revealed that the medication lists in the progress notes were often carried over from previous notes and may not have accurately reflected current medication orders or changes. Both providers indicated reliance on the MAR for the most accurate medication information. The administrator and DON acknowledged awareness that the medication lists in the progress notes were not always accurate, but were not familiar with the specific process by which the medication list was generated for the notes. The failure to restart Eliquis after the procedure and the continued listing of the medication as active in progress notes were not identified or corrected in a timely manner, resulting in inaccurate documentation of the resident's medication regimen.