Failure to Document Assessments After Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete, accurate, and readily accessible medical record for a resident who experienced a significant medication error. The resident had diagnoses including heart failure, transient cerebral ischemic attacks, and use of anticoagulants, and was documented on the admission MDS as having moderate cognitive impairment and taking an anticoagulant. On the date of the incident, a progress note recorded that a trained medication aide notified the nurse that the resident had been given another resident’s medications by mistake. A medication error incident report documented that the resident had inadvertently received another resident’s medications and subsequently became unresponsive, requiring transfer to the emergency department. A later progress note described the resident as unresponsive, with eyes closed and not responding to verbal commands, and only a facial grimace in response to a sternal rub, along with recorded vital signs and the decision to call an ambulance. During interview, the LPN on duty stated that she had taken the resident’s vital signs multiple times and performed assessments after the medication error but did not enter any of these vital signs or assessments into the electronic health record. The DON confirmed that these vital signs and assessments should have been documented in the resident’s record to ensure it was complete and accurate, consistent with the facility’s Charting and Documentation Policy, which requires documentation of services provided, changes in condition, and events or incidents involving the resident, and specifies that documentation must be objective, complete, and accurate.
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