Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was admitted with diagnoses including an aneurysm of the upper extremity and rapidly progressive nephritic syndrome, had a physician's order for Sevelamer to be administered three times daily. However, the MAR showed discrepancies in the administration times and doses, indicating that the medication was not consistently available or administered as prescribed. The progress notes revealed multiple instances where Sevelamer was not available, and the pharmacy was contacted repeatedly for delivery. Despite these efforts, the medication was documented as administered even when it was not available, and the physician was notified of the unavailability. The Transitional Care Unit Manager confirmed that the medication was not in the facility before a recent delivery, and a nurse admitted to documenting the administration without actually giving the medication. The Director of Nursing acknowledged the expectation for accurate documentation and communication with physicians regarding medication availability. However, there was uncertainty about the steps taken by the facility's Unit Managers to document their communication efforts. The facility's policy emphasized the importance of maintaining accurate and accessible medical records, but the documentation practices did not align with these standards, leading to the deficiency.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #3 was obtained during a historical document review and interview process. On __, the physician for resident #3 was notified of the medication variation/inaccuracy of documentation of administration; new orders to administer the Sevelamer once a day at 5pm while the resident was in the facility instead of administration at the clinic. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On __, the Director of Nursing/designee completed a 7 day look audit of active residents to ensure accuracy of the medical record and accurate documentation of medication administration to identify other residents having the potential to be affected. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On __, the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring accuracy of the clinical record and accurate documentation of medication administration. Newly hired licensed nurses will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents clinical records 3 times weekly X 4 weeks and then weekly X 2 months to ensure accuracy of the clinical record with emphasis on documentation of medication administration. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.