Inaccurate Medical Record Documentation for Medication Administration
Penalty
Summary
The facility failed to ensure the accuracy of the medical record for a resident with multiple diagnoses, including dysphagia following a stroke, gastrostomy status, and a physician order for nothing by mouth (NPO). Despite the resident's NPO status and use of a feeding tube, the medical record and Medication Administration Record (MAR) documented that several medications, including Keppra, Lamictal, and Tramadol, were administered by mouth. Observations confirmed that these medications were actually given via the feeding tube, not orally as recorded. Interviews with nursing staff, including LPNs and an RN, revealed that all were aware the resident received medications through the feeding tube and not by mouth, but continued to document administration as oral on the MAR. The Clinical Coordinator and Director of Nursing acknowledged the discrepancy, stating that the medical record was inaccurate and that clarification should have been sought from the physician regarding the medication orders. The facility's policy required accurate reference to current orders and reporting of errors, which was not followed in this instance.