Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as R603, who was admitted with a diagnosis of unspecified dementia with agitation. On January 20, 2025, it was documented in the nursing progress notes that 500 mg of acetaminophen was administered to the resident for pain relief, with a positive effect noted. However, the Licensed Practical Nurse (LPN) and the Registered Nurse (RN) involved did not document the administration of acetaminophen in the resident's electronic administration record, which is a requirement according to the facility's policy titled 'Charting and Documentation.' Interviews with the LPN and RN confirmed that the medication was given, but the failure to document this in the electronic administration record was evident. This lack of documentation is a violation of the facility's policy and the regulatory requirement to maintain complete and accurate medical records, as it did not reflect the care provided to the resident. The deficiency was identified during a review of clinical records, staff interviews, and facility policy, highlighting a lapse in the documentation process for resident care.
Plan Of Correction
Step 1 R603 Resident discharged from facility Step 2 Current residents that have used prn pain medications over the last 30 days will be reviewed to ensure medication administration was documented, non-pharm interventions were documented, and a pain assessment was conducted prior to medication administration. Step 3 All nursing staff educated on ensuring observations, medications administered, services performed, etc., will be documented in the resident's clinical records. Step 4 Managers/ designee will conduct audits weekly x4, monthly x 2 to ensure medication administration policy is followed as per facility protocol. All results will be presented at QA for further review.