Failure to Document Diagnosis Consistent With Seizure Medication Orders
Penalty
Summary
The facility failed to accurately document a medical diagnosis in the clinical record for one of three residents reviewed, resulting in a discrepancy between prescribed medications and recorded diagnoses. The resident was admitted with diagnoses of essential tremor and major depressive disorder. Subsequent physician orders included Depakote 250 mg once daily by mouth for seizures, dated January 2, 2024, and Primidone 50 mg, 0.5 tablet by mouth at bedtime for seizures, dated January 3, 2024. Review of the resident’s clinical record showed no documented diagnosis of seizures despite these seizure-related medication orders. The facility’s Medication Monitoring policy, dated January 2024, states that the Medication Regimen Review (MRR) should include review of the medical record to prevent, identify, report, and resolve medication-related problems and irregularities. During an interview, the Nursing Home Administrator confirmed the findings that the seizure diagnosis was not documented in the resident’s record. This deficiency was cited under 28 Pa. Code 211.12(d)(3)(5) related to nursing services.
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