Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurately documented for four residents. For one resident with anxiety disorder, hypertension, and COPD, Ativan was documented as administered on the medication administration record, but not signed out on the controlled substance administration record, as confirmed by the LPN/Unit Manager. Another resident with diabetes, end stage renal disease, and a left leg amputation received Tramadol, which was signed out on the controlled substance administration record but not documented on the medication administration record for multiple doses, as confirmed by the President of Clinical Operations. A third resident with peripheral vascular disease, dementia, and diabetes was observed wearing Prevalon boots, but there was no physician's order for the boots and they were not included in the plan of care, despite the boots being in use for several months. For a fourth resident with anxiety disorder, fibromyalgia, and chronic pain syndrome, Tramadol was signed out as administered on the controlled substance administration record but not documented on the medication administration record for several doses. These discrepancies were confirmed by facility leadership during interviews.