Inaccurate Medication Documentation by LPN
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident, identified as Resident 12, as evidenced by discrepancies in the medication administration records (MAR) maintained by an LPN, referred to as Employee 9. The clinical record review revealed that Resident 12 had several physician orders for Ativan and Morphine, with specific dosages and administration times. However, the MAR for October, November, and December 2024 showed multiple instances where Employee 9 documented medication administration and its effectiveness either significantly after the actual administration time or pre-documented the effectiveness before it could be accurately assessed. This included instances where the documentation was completed hours after the medication was administered or where the effectiveness was recorded before the time it was supposed to be evaluated. The discrepancies in documentation included pre-documenting the effectiveness of PRN Ativan and Morphine doses, as well as failing to timely document the administration of these medications. For example, on several occasions, Employee 9 documented the administration of Ativan and Morphine hours after they were given, and in some cases, recorded the effectiveness of the medication before the time it was supposed to be assessed. These actions led to incomplete and inaccurate clinical documentation, which was confirmed during an interview with the Director of Nursing.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Interview with employee 9 reveals resident 12 received medications as ordered. 2. Employee 9 was coached on medication documentation at time of administration. 3. All licensed staff were educated to document at time of administration of ordered medications. 4. A random audit of documented medication administration times for five residents will be completed weekly x4 then monthly x2 with results reported to QAPI. 5. Compliance date: January 28, 2025.