Incomplete and Inaccurate Documentation of Antipsychotic Medication Orders and Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident receiving antipsychotic medication. The resident had diagnoses of bipolar disorder with depressive episodes and Alzheimer’s disease, with a BIMS score indicating some memory deficits, and a care plan identifying use of an antipsychotic for bipolar disorder with monitoring for excessive crying and suicidal ideation. Physician orders directed Aripiprazole 5 mg in the morning, later decreased to 2 mg, with a one-time 2 mg dose ordered for a specific morning and then an increase back to 5 mg at bedtime on a later date. On one date, the resident was found with a call bell cord wrapped around the neck, was assessed, and sent to the ED and returned the same day; the care plan included one-to-one observation. Review of the Medication Administration Record (MAR) for that month showed the one-time 2 mg dose was signed as given in the morning, but documentation did not show administration of Aripiprazole 2 mg at bedtime on two consecutive days. Interviews revealed that the 3–11 PM LPN on the first evening did not administer the bedtime dose because the 7–3 PM RN had communicated that the medication had already been given that morning as a one-time dose and that the daily bedtime dosing was to start the following day; the LPN did not sign the MAR and did not document a note explaining the omitted bedtime dose. The RN who transcribed the order acknowledged entering the daily bedtime Aripiprazole 2 mg order incorrectly so that it appeared on the MAR for the same day the one-time morning dose was given, instead of starting the next day, and stated she should have ensured the order was correct before signing it. Another 3–11 PM LPN reported administering the bedtime dose on the following day but failing to sign it on the MAR, acknowledging responsibility for ensuring complete and correct documentation. The DON confirmed that the order had been transcribed incorrectly and that staff are expected to sign off all medications and document reasons when medications are not administered, consistent with the facility’s Charting and Documentation policy, and that a policy on Transcription of Physician’s Orders was not available.
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