Incomplete Documentation of Medication Error and Resident Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical record documentation regarding a medication error for one resident. The resident had multiple diagnoses, including cerebrovascular disease, type II diabetes mellitus, major depressive disorder, epilepsy, hypertension, cortical blindness, anxiety disorder, and morbid obesity, and was receiving antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications, as well as oxygen therapy and hospice care. A physician order dated 11/24/25 directed that morphine sulfate oral solution 20 mg/mL be given at 0.5 mL by mouth every two hours as needed for pain or shortness of breath, and there was no active order for Dilaudid. On 11/25/25, an event note documented that the resident, who was sitting in a recliner watching television, reported pain, and that medication was not administered according to the six rights of medication administration. The assessment noted oxygen saturation below 90%, application of as-needed oxygen with improvement above 90% on 2.5 L via nasal cannula, and that the resident was drowsy but resting comfortably in bed. The medical record did not contain documentation of the specific medication error, including the medication name, dose given, or detailed description of the incident, nor did it include ongoing assessments of the resident’s health status or physician instructions related to the error. There were no additional progress notes between the event on 11/25/25 and 11/29/25, and the next progress note on 12/01/25 did not mention the medication error, ongoing assessments, or physician recommendations following the error. During interviews, the DON stated that an LPN had reported administering two different doses of Dilaudid in error instead of the ordered morphine, but the DON could not identify the resident for whom the Dilaudid was prescribed, and there was no verification of the amount of Dilaudid in the bottle before or after the incident. The DON confirmed that the medical record lacked documentation reflecting the details of the medication error, and the Administrator acknowledged there was no documented facility guidance or procedures to ensure accurate resident information and experiences, including medication errors, were consistently recorded in the medical record.
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