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 with diagnoses including type 2 diabetes, complained of severe pain rated 10 out of 10. Although the resident reported the pain to a nurse and was subsequently given medication by a Registered Nurse (RN), the administration of the medication was not documented in the MAR. Additionally, there was no progress note entered by the RN regarding the administration of the medication or the resident's pain on that day. The facility's policies require that all services provided, including medication administration, be documented accurately in the medical record to facilitate communication among the interdisciplinary team. The General & Restorative Unit Manager and the Director of Nursing both emphasized the importance of accurate documentation, which was not adhered to in this instance. The failure to document the medication administration and the resident's condition was a deviation from the facility's established procedures and expectations.
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 nurses' 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.