Inaccurate Medication Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident, as required by its own medical records policy and accepted professional standards. The facility’s policy states that each resident must have an electronic clinical record that is complete, accurate, readily accessible, and systematically organized, including assessments, care plans, services provided, and diagnostic information. For one resident with dementia and hypertensive heart disease without heart failure, the electronic medical record contained a progress note dated 02/10/2026 documenting a dosing regimen for Multaq 400 mg as 2 tablets by mouth twice daily for paroxysmal atrial fibrillation. This documented regimen exceeded the usual dosing of 1 tablet twice daily and the maximum recommended single dose of 1 tablet, as indicated by an FDA black box warning. Further review of the resident’s February 2026 MAR showed no evidence of any physician’s order for Multaq, either current or discontinued, despite the progress note describing Multaq dosing. During interviews, the DON confirmed that the resident did not have a physician’s order for Multaq in the EMR. The DON also reviewed a subsequent progress note dated 02/12/2026 that stated an order review had identified Multaq as entered as 2 tablets/400 mg BID instead of the correct 1 tablet/400 mg BID, and that the order was immediately changed. The medical director later confirmed that this documentation had been entered incorrectly in the resident’s medical record, demonstrating that the resident’s EMR contained inaccurate and incomplete medication documentation.
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