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Based on interview, record review and review of facility policy, the facility failed to accurately complete 6 of 30 patient medical records reviewed for identified patient allergies to the medication administration record (MAR). Failure to accurately document identified patient allergies on the patient MAR could result in patient adverse medication reactions (#1, 3, 4, 5, 13 & 27).

Findings:

1. Review of patient #1's record revealed documented allergies to Risperdal, Zoloft, Cogentin, and Depakote on the "Health Screening Form" which was dated 5/29/14 at 4:25 PM. Review of the "Nursing Physical Assessment" dated 5/29/14 at 11:05 PM documented Allergies as "NKA" (no know allergies). Review of the physician order sheets revealed 2 order sheets which documented allergies as "Risperdal, Zoloft, Cogentin, and Depakote", 6 physician order sheets documented the patient's allergies as "NKA", and 4 physician order sheets were incomplete and documented nothing in the allergy space. The record contained 8 nursing MAR sheets, which were observed to have a printed section for "ALLERGIES". All 8 MAR sheets were blank and did not document any allergies for the patient.

In an interview with the vice president/acting director of nursing and the risk manager at 2:20 PM on 11/14/14, they confirmed the missing and conflicting information and stated it was the expectation of the facility to have accurate and complete patient medical record information.

Review of the facility policy "Medical Record Standards", revised 12/05/13, read in part, "Purpose: To establish minimum standards regarding the access to information contained in the medical record as well as to ensure that all information contained in the record is up to date, accurate and as complete as possible....To serve as a means of communication among all appropriate staff (on a need to know basis in order to perform their job duties) who are involved in the client treatment....Information on any variances in treatment, such as the following: 5) Procedures that place the client at risk or cause unusual pain."

2. Review of patient #3's record revealed the patient allergies documented as "NKA" on the "Nursing Physical Assessment" dated 9/05/14 6:05 PM and the physician order sheets. Review of the MARs did not reveal that no documentation was transferred to the patient MAR, and the section marked "Allergies" was blank.

3. Review of patient #4's record revealed a patient allergy to Penicillin documented on the receiving order and all 4 of the physician order sheets. The "Nursing Physical Assessment" dated 6/08/14 documented a patient allergy of penicillin. Review of the patient MARs did not reveal that documentation was transferred to the patient MAR, and the section marked "Allergies" was blank.

4. Review of patient #5's record revealed a patient allergy to Risperdal on the receiving, admission and 8/04/14 physician order sheet. The physician order sheet dated 8/04/14 allergy section was left blank documenting no allergy and all 3 of the patient MARs did not reveal that documentation was transferred to the patient MAR, and the section marked "Allergies" was blank.

5. Review of patient #13's record revealed "NKA" was documented on the "Nursing Physical Assessment" and the physician order sheets. Review of the patient's MARs did not reveal that documentation was transferred to the patient MAR, and the section marked "Allergies" was blank.

6. Review of patient #27's record revealed documented allergies of "NKA" on the "Nursing Physical Assessment" and physician orders. Review of the patient's MARs did not reveal that documentation was transferred to the patient MAR, and the section marked "Allergies" was blank.

In an interview with the vice president/acting director of nursing and the risk manager at 2:20 PM on 11/14/14, they confirmed the missing and conflicting information and stated it was the expectation of the facility to have accurate and complete patient medical record information.

Review of the facility policy "Medical Record Standards", revised 12/05/13, read in part, "Purpose: To establish minimum standards regarding the access to information contained in the medical record as well as to ensure that all information contained in the record is up to date, accurate and as complete as possible....To serve as a means of communication among all appropriate staff (on a need to know basis in order to perform their job duties) who are involved in the client treatment....Information on any variances in treatment, such as the following: 5) Procedures that place the client at risk or cause unusual pain."