Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain complete medication records with staff signatures according to professional standards of clinical practice for Resident #23. The resident, who had diagnoses including dementia and arthritis, was observed on a pressure-relieving mattress. A review of the Treatment Administration Record (TAR) revealed blank areas where nurses' initials should have been, indicating the completion of treatment with Medihoney, a topical cream ordered for daily application to a sacral wound. The blanks were noted on specific dates in December 2024, and interviews with nursing staff confirmed that there should not be blanks on the TAR, as it either indicated a failure to sign or a failure to complete the treatment. The facility also failed to follow physician orders regarding medication administration for Resident #51, who had diagnoses including hypertension, end-stage renal disease, and schizophrenia. The resident had a physician order for Midodrine HCL to be administered with specific parameters to hold the medication if the systolic blood pressure (SBP) was greater than 135. However, the electronic Medication Administration Record (eMAR) showed that the medication was administered on several occasions when the SBP exceeded 135, contrary to the physician's order. Interviews with LPNs revealed that the medication was documented as administered, and one LPN admitted to possible incorrect documentation without providing further explanation. The facility's policy on administering medications, revised in March 2020, states that medications must be administered safely, timely, and as prescribed, including adherence to any required time frames. The Director of Nursing acknowledged the issues with medication administration and documentation, confirming that Midodrine should be held for SBP greater than 135. The surveyor noted these deficiencies in the facility's adherence to medication administration policies and procedures.
Plan Of Correction
F658- Services Provided Meet Professional Standards What corrective action will be accomplished for those residents affected by the deficient practice? A statement was obtained by the Director of Nursing from the nurse who completed the treatment for resident #23. Statement indicated the residents treatment was completed. Resident #23 Treatment administration record could not be retroactively updated to include the initial of the nurse who completed the treatment. The Medical Director was made aware of the residents parameters on the medication administration record for Midodrine. The Medical Director provided no new orders. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this alleged deficient practice. Treatment Administration Records were reviewed by Unit Managers for residents and no concerns or blanks were identified. Unit Managers reviewed charts for residents on Midodrine and no concerns were noted for blood pressure. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? Medication administration policy was reviewed. Nurses were educated on the importance of documenting treatments on the treatment administration records. Nurses were also educated by the Educator on monitoring and following medication parameters. Unit Managers or designee will monitor Treatment and Medication Administration records to ensure nurses are documenting and following medication parameters. How will the corrective action be monitored to ensure the deficient practice will not recur? Director of Nursing will monitor Treatment/Medication Administration Records once a week for 30 days, then monthly x 3 to ensure nurses are documenting or following parameters. The results of the audit will be reviewed at the monthly QAPI team chaired by the facility administrator.