Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with physician orders for three residents. For Resident 121, there was a lack of documentation in the Medication Administration Record (MAR) for several medications, including Lantus, Levothyroxine Sodium, Melatonin, Acetaminophen, and blood sugar monitoring. The progress notes did not indicate whether these medications and monitoring were administered or provide a rationale for not following physician orders. Resident 221's Treatment Administration Record (TAR) showed that staff did not document care for the Foley catheter as per physician orders. The orders required emptying the Foley drainage bag every shift and recording output, as well as irrigating the catheter with sterile normal saline every shift. Documentation was missing for several shifts in January and February 2025, and the Director of Nursing confirmed that staff should have documented the catheter care. For Resident 338, the MAR lacked documentation for the administration of several medications, including Atorvastatin Calcium, Melatonin, Ativan, Baclofen, and Insulin Lispro on specific dates. The progress notes did not indicate whether these medications were administered or provide a rationale for not following physician orders. The Director of Nursing acknowledged that the MAR should be completed at the time of administration or resident refusal.
Plan Of Correction
This provided submits the following plan of correction in good faith and to comply with Federal regulations. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident 121's physician was notified of the MAR blanks from January 19th, 2025 for the following medications: Lantus 15 units, Lantus 46 units, Levothyroxine Sodium, Melatonin 3 Milligrams, Acetaminophen 325 Milligrams. Resident 121's physician was also notified of the MAR blank on January 19th, 2025 in regards to monitoring blood sugar levels before bedtime. Resident 221's physician was notified of catheter care not documented on the TAR from the following shifts and dates: Evening shift of January 5th, 2025, day and night shift on January 9th, 2025, day shift on January 14th, 2025, evening shift of January 31st, 2025, evening shift of February 1st, 2025, day shift on February 5th, 2025, evening shift on February 14th, 2025, evening shift on February 15th, 2025 and evening shift on February 16th, 2025. Resident 221's physician was also notified of irrigation of the Foley was not documented on the TAR for the following shifts and dates: Evening shift on February 1st, 2025, day shift of February 5th, 2025, evening shift on February 14th, 2025, evening shift on February 15th, 2025 and evening shift on February 16th, 2025. Resident 338's physician was notified of the MAR blanks from January 19th, 2025 for the following medications: Atorvastatin Calcium 40MG, Melatonin Oral Tablet 3 MG, Ativan .5 MG, Baclofen Oral Tablet 10MG and Insulin Lispro. 2. To identify other residents that have the potential to be affected, the DON/designee will audit January 19th, 2025 MARS for residents that were assigned to the same nurse and/or nurses who were assigned to resident 121 and to resident 338 on that day. The DON/designee will audit MAR's and TAR's of residents that have a catheter to ensure catheter care and irrigation of their Foleys are being documented on. 3. Licensed and certified staff will be educated by staff development/designee on the importance of following physician orders in regards to medication administration, providing catheter care/Foley irrigation. 4. The DON/designee will conduct an audit 1x a week for 4 weeks on residents MARS to ensure there is no blanks on medication administration and blood sugar monitoring. The DON/designee will conduct an audit 1x a week for 4 weeks on residents with a catheter that catheter care is documented in the TAR and foley irrigation is documented in the TAR. Results of the audits will be reviewed at the QAPI meeting to determine if future action/audits are needed.