Incomplete Documentation of Treatment Administration
Penalty
Summary
The facility failed to ensure complete documentation related to treatment administration for a resident, identified as Resident R1. A review of the facility's policy on 'Treatments' indicates that a licensed nurse or medical technician is required to perform treatments as ordered and document the administration on the Treatment Administration Record (TAR), including the patient's response, refusal of treatment, and notification of the physician. However, the clinical record for Resident R1 revealed a lack of documented evidence for the administration of Hydrocortisone External Cream 2% on several specified dates, despite a physician's order for the treatment to be applied twice daily for a rash. There was also no documentation of the resident's refusal of treatment or any other reason for the missed treatments on the specified dates.
Plan Of Correction
Resident 1 no longer resides in the Center. An initial 30-day lookback audit will be conducted for all current residents to ensure that the licensed nursing staff has completed the treatment administration records. The Director of Nursing/designee will educate licensed nursing staff on the policy related to treatment administration record documentation. The Director of Nursing/designee will conduct random audits of resident treatment administration records weekly x 3 weeks and then monthly x 2 to ensure professional staff has completed the treatment administration documentation. The Director of Nursing or designee will report all findings to be discussed in QAPI meeting x 3 months.