Failure to Accurately Document and Administer Ordered Medication
Penalty
Summary
The facility failed to ensure accurate documentation and proper maintenance of medical records for a resident admitted with end-stage renal disease dependent on dialysis and a disorder of phosphorus metabolism. The resident was prescribed Sevelamer HCl, an oral medication to manage hyperphosphatemia, to be administered three times daily with meals. Review of the Medication Administration Record (MAR) showed multiple instances where doses were marked as "OS" (see nurses' note) or as administered, but corresponding nurses' notes indicated the medication was not available. The MAR inaccurately reflected that some doses were given when, in fact, the medication was never present in the facility during the resident's stay. Interviews with the family member and the Director of Nursing (DON) confirmed that the resident did not receive any doses of Sevelamer from admission until discharge, as the medication could not be obtained from the pharmacy. The DON verified that the medication was not in the facility at any time and acknowledged that the MAR entries indicating administration were not accurate. The family was notified of the issue only after several days, and the resident was eventually transferred to a hospital due to a change in condition. The inaccurate documentation and failure to provide the ordered medication constituted a deficiency in maintaining accurate and complete medical records.