Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for three residents, as evidenced by missing entries of nurses' signatures, initials, or codes on the medication administration records (MARs) for multiple medications, dates, and times. The Director of Nursing (DON) confirmed that the absence of documentation on the MAR indicates that the medication was not administered, and stated that it is the expectation for nurses to document on a progress note if a medication is unable to be given for any reason. The facility's policy also requires that the person administering medications records the administration on the MAR at the time the medication is given and reviews the MAR at the end of each medication pass to ensure all doses are documented. The affected residents had complex medical histories and required multiple medications. One resident had diagnoses including metabolic encephalopathy, severe malnutrition, diabetes, dementia, and other serious conditions, and was noted to have severely impaired cognitive skills. Another resident, with intact cognition, had diagnoses such as paraplegia, pressure ulcers, anemia, and osteomyelitis. The third resident, also with intact cognition, had conditions including seizures, diabetes, hypertension, anemia, and a stage 4 pressure ulcer. For each of these residents, specific medications and administration times were identified where documentation was missing, indicating a failure to administer or record the administration of prescribed medications. Review of facility policies and job descriptions confirmed that both registered nurses and licensed practical nurses are required to perform routine charting duties in accordance with established documentation policies. The facility's drug administration guidelines specify that only licensed personnel may administer medications and must record the administration on the MAR at the time the medication is given. The policy further states that all administered doses must be documented before the end of the medication pass, and any withheld, refused, or rescheduled doses must be properly noted on the MAR.