Failure to Maintain Accurate and Complete Medical Records Following Medication Error
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, a medication error occurred when an LVN administered another resident's medications to a resident with a history of epilepsy, hypotension, cardiomyopathy, and schizophrenia. The LVN did not document the medication error, the medications given, assessments, vital signs, change of condition, notifications to the physician and responsible party, follow-up orders, or the resident's transfer to the hospital by EMS in the resident's permanent medical record. Instead, the LVN wrote a separate handwritten statement that was not included in the official medical record. Additionally, the facility failed to upload the resident's hospital records from the hospital stay following the medication error into the permanent medical record. Staff interviews revealed confusion about the process and responsibility for uploading hospital records, with no designated medical records staff and inconsistent procedures for handling and uploading documents. The ADON was identified as responsible for uploading records, but there was no clear or timely process in place, and hospital records were not available in the electronic record for review several days after the resident's return. The LVN also inaccurately documented medication administration in the Medication Administration Record (MAR), indicating that the resident received her prescribed medications when, in fact, she had received another resident's medications. The LVN admitted to documenting medication administration as medications were removed from packaging rather than after administration, contrary to facility policy. The DON and other staff acknowledged the lack of proper documentation and the importance of accurate records for continuity of care, but facility policy and training were not consistently followed.