Medication Documentation Errors and Missing Physician Visit Notes
Penalty
Summary
The deficiency involves failures in medication documentation and medical record maintenance for multiple residents. For one resident with diagnoses including subarachnoid hemorrhage with loss of consciousness, paraplegia, and traumatic brain injury, the physician ordered Modafinil 100 mg daily at 8:00 a.m. Review of the November, December, and January medication administration records (MARs) and controlled substance records showed multiple discrepancies. On several dates, the MAR reflected administration of Modafinil, but the corresponding controlled substance record was not signed to show it was given. On other dates, the controlled substance record showed additional doses at 8:00 p.m. or duplicate 8:00 a.m. doses without any physician order for those extra administrations. The resident’s clinical record also lacked documentation of any physician or nurse practitioner visits. Additional deficiencies were identified in the timeliness and completeness of physician and nurse practitioner documentation for other residents. One resident with malignant neoplasm of the larynx, liver transplant, diabetes, and acute respiratory failure had an admission date earlier in the year, but the first physician or nurse practitioner progress note in the record was dated several months later. For another resident with paraplegia and traumatic brain injury, the clinical record lacked physician and nurse practitioner visit documentation after a specific date in the spring. A further resident with acute and chronic respiratory failure and congestive heart failure had no documented physician or nurse practitioner visit after a date in the fall. Interviews with staff confirmed expectations and highlighted gaps in practice. An RN stated that medications could not be administered without a physician’s order and that narcotic medications should be signed out on the narcotic sheet when pulled and then signed as administered on the MAR at the time of administration. The DON reported that both the physician and nurse practitioner had been in to see residents but was unsure why the notes were not present in the records. An LPN reported that the nurse practitioner indicated notes had been uploaded on their end and needed to be retrieved by the facility. Facility policies provided by the Regional Nurse Consultant required that each dose of controlled substances be recorded at the time of administration, that medications be administered as prescribed, that physicians or non-physician practitioners write, sign, and date progress notes at each required visit, and that each resident have a current, complete, and available health record including a MAR with date, time, and person administering each medication.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.