Inaccurate Documentation of Clonidine Administration for Absent Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident with a history of stroke, hypertension, repeated falls, and cognitive communication deficit. The resident had a provider order for clonidine 0.3 mg by mouth three times a day for hypertensive urgency, with instructions to hold the dose if the heart rate was less than 60 beats per minute or if systolic blood pressure was less than 100 mmHg. Nursing notes documented that the resident told the receptionist she was leaving the facility in the evening and did not return overnight, prompting staff to search the facility, call her cell phone, and eventually contact the police and file a missing person report. The resident did not return until the following day around midday. Despite the resident being out of the building during this time, the February medication administration audit and medication administration record showed that a scheduled dose of clonidine was documented as administered late that evening, with a recorded blood pressure of 121/74 and pulse of 72, and an administration time that did not match the resident’s actual absence from the facility. During interview, the LPN who documented the dose stated he had given all of the resident’s evening medications at the same time because she preferred to take all pills together and would often refuse a second approach, and he admitted entering the clonidine administration later so it would appear as though it was given as ordered. He could not explain conflicting blood pressure readings, having stated he only approached the resident once for medications and vitals. The DON confirmed that, according to the documentation, the resident was out of the building at the time the clonidine dose and blood pressure check were recorded as given, and facility policies required that medication administration be documented immediately after, never before, and that all charting be objective, complete, and accurate.
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