Inaccurate Medical Records and Medication Administration for NPO Residents
Penalty
Summary
The facility failed to maintain accurate and consistent medical records and physician orders for multiple residents, specifically regarding fall interventions and medication administration routes for residents with NPO (nothing by mouth) orders. For one resident, there was a discrepancy between the care plan and physician orders for fall interventions, with the care plan listing a low bed parameter mattress while the physician orders included 1:1 supervision and floor mats, but no order for a low bed. Additionally, this resident had an active NPO order, yet the Medication Administration Record (MAR) documented the administration of several oral medications over a period of months, despite the NPO status. Two other residents with NPO orders also had MARs indicating the administration of oral medications during their NPO periods. In both cases, the DON reported that medications were given via tube and that nursing staff were aware of the residents' NPO status, but the documentation did not reflect the correct route of administration. These inconsistencies in documentation and failure to accurately follow and record physician orders for both fall interventions and medication administration routes were confirmed by facility leadership during the survey.