Failure to Document Medication Administration
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 readmitted to the facility with diagnoses including type 2 diabetes, complained of severe pain rated at 10 out of 10. Despite informing the nurse, the resident did not receive medication promptly. When the Registered Nurse (RN) eventually administered the medication, she failed to document it in the MAR and did not assess the resident's pain level or location before administration. The facility's policies on charting and documentation, as well as medication administration, require that all services provided, including medications administered, be accurately documented in the resident's medical record. However, the RN did not document the administration of the medication or the resident's response to it. The Unit Manager and Director of Nursing both emphasized the importance of accurate documentation, which was not adhered to in this instance, leading to a deficiency in the facility's compliance with regulatory standards.
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 it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 18 assessed for, No. Notified physician and advised to discontinue order. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents receiving medication have the potential to be affected. An audit was conducted for all current Residents receiving meds to ensure the assessment was completed and the medication administration was documented. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Nursing staff (RNs, LPNs) will receive mandatory Education for all nurses on accurately documenting of prn medications on the MAR. All Nursing staff will be in-service by. Any Nursing staff not in-serviced by this date will be in-serviced prior to their next scheduled shift. We have no Agency staff currently. All newly hired Nursing staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not reoccur: DON, Unit managers or designee will observe 2 nurses medication administration of 2 residents 3 times a week for 2 weeks then 2 nurse's medication administration for 2 residents once a week for (3) months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. (e) The date of compliance is