Failure to Maintain Accurate and Complete Medical Records for Falls and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with its own policies and accepted professional standards for three residents. The facility’s Fall Prevention Program policy, revised 10/01/2025, required that when any resident experiences a fall, staff must document all evaluations, assessments, and actions taken. For a resident with a history of falls, moderate cognitive impairment, and care plan problems including an ADL self-care performance deficit related to stroke and risk for falls, there was a documented fall on 10/3/2025 at 5:30 PM in a Fall Scene Investigation Report and an unwitnessed fall with head injury record. However, the DON stated that the medical record documentation for this resident was not accurate and did not reflect the fall event. The facility’s Medication Administration policy required staff to review the MAR to identify medications to be administered, remove medications from the source, administer them as ordered, and sign the MAR after administration. For a resident with COPD, diabetes mellitus, end stage renal disease, and dependence on hemodialysis, whose care plan included diabetes management and who was cognitively intact per MDS, multiple physician orders were not accurately or completely documented on the MAR. Lacosamide ordered to be given in the evening after hemodialysis on specific days showed no documentation of administration on one date. Levothyroxine ordered once daily had no documentation of administration on a morning dose. A sliding-scale insulin lispro order requiring blood glucose checks every six hours had no documented blood glucose levels at several scheduled times, and metoclopramide ordered before meals for nausea had no documentation of administration at multiple scheduled times. Another resident with type 1 diabetes mellitus with chronic kidney disease, history of stroke, and congestive heart failure, whose care plan also included diabetes management and who had moderate cognitive impairment per MDS, had a physician’s order for sliding-scale insulin lispro to be given three times a day on specified days. The MAR for this resident lacked documentation of the blood glucose level needed to determine the insulin dose at a scheduled time. During an interview, the DON confirmed that medications should be documented on the MAR when administered or withheld, including the reason for holding a medication, and acknowledged that blanks on the MAR for the two residents meant those scheduled medication doses were not documented, further supporting that the medical records were incomplete and inaccurate.
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