Inaccurate Documentation of Bowel Movements and Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for two residents, specifically regarding bowel movement documentation and controlled medication administration. One resident with Stage IV basal cell carcinoma had only three bowel movements documented over a nineteen-day stay, despite nursing staff and the DON acknowledging that the resident had more bowel movements than recorded. The facility’s system was designed to flag when a resident went three days without a bowel movement so that medications could be administered if needed, but the actual frequency of bowel movements was not accurately reflected in the medical record. For the same resident, record review showed multiple instances where hydrocodone-acetaminophen and oxycodone were removed from controlled drug storage, as documented on the Controlled Drug Record, but there was no corresponding documentation of administration on the MAR. Nurse #1 confirmed that she had administered both hydrocodone-acetaminophen and oxycodone at the times she signed out the medications but failed to document these administrations on the MAR. Another nurse (Nurse #6) also reported administering a dose of hydrocodone-acetaminophen that she removed from storage but forgot to sign for on the MAR. The DON stated that the resident was at risk for constipation due to pain medications and acknowledged that the record was incomplete and did not accurately reflect the resident’s status. A second resident with vertebrae osteomyelitis and low back pain had an order for scheduled Oxycontin and PRN oxycodone for breakthrough pain. Review of this resident’s MAR and Oxycontin Controlled Drug Record showed that a nurse (Nurse #13) initialed that a scheduled Oxycontin dose was given, even though she did not administer it because the resident appeared sedated. Nurse #13 explained that she had signed the MAR before deciding to hold the dose and was unfamiliar with how to correct the electronic MAR to show that the medication was not actually administered. She confirmed that the medical record was therefore not accurate. The interim Administrator stated an expectation that medical records be complete regarding documentation of bowel movements and controlled medications.
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