Inaccurate Medication Routes and Treatment Documentation in Medical Records
Penalty
Summary
The deficiency involves failures to maintain accurate and complete medical records for two residents. For one resident with a history of severe dysphagia from a previous stroke and an NPO (nothing by mouth) diet order, multiple medication orders in the electronic medical record (EMR) were entered with the route as "by mouth" instead of via gastrostomy tube (g-tube). These included lorazepam, sertraline, and geri-tussin DM. The March Medication Administration Record (MAR) showed these medications as administered as ordered by mouth over multiple days, even though the resident was NPO. Nursing staff who regularly cared for this resident reported that all medications were always crushed and administered through the g-tube and that the resident did not receive medications by mouth. One nurse stated she had not noticed that some medications were ordered by mouth on the MAR, while another nurse acknowledged she had noticed the incorrect route but did not correct it due to time constraints. The Nurse Practitioner confirmed that she entered the orders and that the EMR defaulted to the oral route, which she failed to manually change to g-tube, resulting in inaccurate documentation of the administration route in the medical record. For a second resident, there was an order for knee-high compression hose to be applied in the morning and removed in the evening. The March Treatment Administration Record (TAR) showed staff initials indicating that the compression hose were applied and removed daily, with one exception. However, observation revealed the resident was not wearing compression hose, and the nurse aide responsible for treatments stated the resident did not wear them and could not explain why the TAR had been initialed as if they were applied. A nurse, the ADON, and the DON all reported that this resident frequently refused compression hose and that refusals should have been documented as such on the TAR rather than initialing as if the treatment had been completed, indicating inaccurate documentation of treatment administration and refusals in the medical record.
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