Incomplete and Inaccurate Medical Records and Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that medical records for residents were complete and accurately documented, as evidenced by discrepancies and omissions in both electronic and paper records for 14 out of 104 residents. Staff interviews revealed inconsistent methods for determining which residents required their medications to be crushed, with reliance on standing orders, report sheets, and verbal handoffs, none of which consistently reflected current physician orders or resident needs. The standing order "May crush medications unless contraindicated" was present in every resident chart, making it unclear which residents specifically required crushed medications, and administration orders were missing in the electronic medical record for some residents who had physician orders for crushed medications. Further review of nursing unit report sheets uncovered multiple inaccuracies, such as the inclusion of information for residents who were deceased or discharged, missing or incorrect code status designations, and absent or outdated information regarding medication administration methods. For example, some residents who required crushed medications were not designated as such on the report sheets, and code status information was not updated to reflect current physician orders. In several cases, residents' names were missing from the correct bed locations, or information for previous occupants remained on the sheets. Interviews with nursing staff and the Director of Nursing confirmed a lack of communication between departments, particularly between speech therapy and nursing, regarding which residents required physician orders for crushed medications. The Nursing Home Administrator and Director of Nursing acknowledged that the report sheets used by staff were inaccurate and confirmed the failure to maintain complete and accurate medical records for the affected residents.