Incomplete and inaccurate medication orders were found for two residents after record review and staff interviews. One resident’s Toujeo insulin glargine order listed conflicting clinical indications, with staff stating the order had been mistyped, and another resident’s hydroxyzine HCl PRN anxiety order omitted the dose even though the resident had previously been receiving 25 mg tablets.
Incomplete and inaccurate MAR documentation: A resident with CHF and bacteremia had duplicate statin orders transcribed to the MAR in error, with one statin listed as both held and administered on different shifts, and an IV Cefepime dose left unsigned on the MAR. The CNO verified the pharmacy delivery and dose counts, and stated the duplicate orders and blank MAR entry were documentation errors.
Incomplete Oxygen Orders in Clinical Records: The facility failed to maintain accurate and complete records for residents receiving O2 therapy. A resident with multiple diagnoses, including respiratory failure, had an expired O2 order in the chart even though the DON said O2 had been re-ordered; two other residents were observed on O2 at 2 L/minute, but their records had no physician O2 orders, and the DON confirmed the orders were missing.
Inaccurate Medical Record Diagnosis Documentation: A resident admitted with multiple psychiatric diagnoses had a physician-documented active diagnosis of generalized anxiety disorder, but the diagnosis was not listed as active in the medical record. The ADON confirmed the record omission during interview.
A resident's partial care plan and nursing note were included in Resident Council Meeting minutes, exposing PHI such as behavior goals, interventions, foot information, medications, and treatment refusals. Staff stated the minutes binder was available to the public and could be viewed by anyone who requested it.
A resident’s chart contained conflicting code status information: the admission record, transfer orders, and order summary listed DNR, while the POST in the EMR and care plan reflected Full Code/CPR. Staff interviews showed the LPN, RN, and Medical Records all relied on the POST or POST book for emergency code status, but the order was not updated to match the POST and the discrepancy was missed in the audit process.
A resident with emphysema, muscle weakness, and a need for assistance with personal care had multiple scheduled medications that were not documented as administered on the MAR over two consecutive days. The MAR entries for midday and bedtime medications on one day and early morning medications on the following day were left blank, with no codes or notations indicating why the medications were not given. The DON later confirmed the resident was in the hospital during this period and stated that nursing staff should have documented this on the MAR and that there should never be blanks on the MAR, resulting in an incomplete and inaccurate medical record.
The facility failed to secure protected health information and to maintain accurate behavioral documentation. A medication cart was left unattended with a laptop screen active, displaying the electronic medical record system with resident information visible, and the responsible LPN admitted she had not locked the screen. In a separate issue, a resident with generalized anxiety disorder, mild neurocognitive disorder, and schizoaffective disorder had behavior monitoring records indicating repeated suicidal statements, as required to be monitored by the care plan, but the DON later reported the resident had not made such statements and that the same nurse had inaccurately documented these entries on multiple dates.
Surveyors observed a medication cart left unattended in a hallway with a laptop logged into the EMR system, displaying multiple resident records, and no staff present to monitor or secure the information. In an interview, the Interim DON confirmed that the facility’s expectation is that resident records remain secured to prevent unauthorized access, indicating that this situation did not meet established standards for protecting resident information.
Two residents’ records were not maintained accurately and completely. For one resident with dementia and a history of falls, an INTERACT hospital transfer form listed vital signs from nearly a week before the actual transfer, which the ADON confirmed did not reflect the resident’s condition at the time of transfer. For another resident with dementia and visual hallucinations, a physician order required per-shift documentation of target behaviors and specific interventions, but behavior monitoring records showed multiple behavior episodes without corresponding documentation of the ordered interventions, and the DON acknowledged that the record did not accurately reflect the interventions used.
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