Failure to Accurately Document Medication Administration and Transcribe Orders
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) and treatment administration records (TARs) accurately reflected the medications and treatments administered to residents. For one resident with a history of gout and chronic kidney disease, there was no documentation of the administration of prescribed topical treatments and oral medications on specific dates, despite the resident reporting that all medications and treatments were received as ordered. Interviews with nursing staff revealed that medications were administered but not documented due to staff being busy or forgetting to sign off on the MAR or TAR. Additionally, the facility did not ensure that medication orders were correctly transcribed into the electronic health record (EHR) for another resident with heart failure and moderate cognitive impairment. A physician's order for a diuretic medication included specific parameters for holding the medication based on blood pressure readings. However, the order was incorrectly transcribed into the EHR, with one entry instructing staff to hold the medication for a systolic blood pressure greater than a certain value, which was acknowledged as a mistake by the nurse responsible for the transcription. Facility policy required that all medication administrations be documented in the MAR or TAR after administration, and that physician's orders be transcribed accurately. Interviews with the Director of Nursing, Administrator, and Medical Director confirmed expectations for proper documentation and transcription, and staff acknowledged the errors in both documentation and order entry.