Failure to Accurately Document Held Medications in Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not properly documenting medications that were held according to physician orders. Specifically, the physician had ordered that certain blood pressure and heart failure medications be held if the resident's systolic blood pressure was below 110 mmHg. Despite this, the Medication Administration Record (MAR) indicated that these medications were administered on dates when the resident's blood pressure was below the specified threshold. However, the nurse involved stated during interview that she did not actually administer the medications on those dates, but instead must have documented them as given in error. She also failed to document that the medications were held, as required by facility policy. The resident involved had multiple diagnoses, including sepsis, pneumonia, and hypertension, and was dependent on staff for all activities of daily living with severely impaired cognitive skills. The Assistant Director of Nursing and Director of Nursing both confirmed that the nurse should have held the medications and documented this action accurately in the MAR, using the appropriate code for held medications. The facility's policy required that all services provided, including medications administered or held, be documented objectively and completely in the resident's medical record.