Failure to Accurately Document Administration of Sublingual Nitroglycerin
Penalty
Summary
The facility failed to maintain an accurate and adequately comprehensive medical record for one resident when documentation did not reflect the administration of sublingual nitroglycerin given for chest pain. The resident, who had diagnoses including cerebral infarction, paroxysmal atrial fibrillation, hypertensive urgency, adult failure to thrive, and essential hypertension, was assessed as having moderately impaired cognition on the most recent MDS. On the date in question, an incident report, an outside hospital history and physical, and an SBAR nursing communication note all indicated that the resident was administered a sublingual nitroglycerin tablet at the facility in response to complaints of chest pain prior to transfer by ambulance. Despite these records and a CNA’s interview confirming they witnessed a medication being placed under the resident’s tongue for chest pain, the resident’s facility medical record did not contain any progress note documenting the administration of a sublingual medication or nitroglycerin on that date. Additionally, the resident’s MAR for the month showed no entry indicating that sublingual nitroglycerin had been administered. The DON confirmed that, aside from the notation on the incident report referencing medication given without an order, there was no facility-produced documentation identifying that the resident received sublingual nitroglycerin.
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