Failure to Timely Document PRN Medication and Wound Care Orders
Penalty
Summary
A deficiency was identified when a registered nurse administered two tablets of Acetaminophen 325 mg to a resident who complained of back pain, but failed to document the administration in the resident's Medication Administration Record (MAR) at the time of administration. The nurse confirmed the omission during a review of the MAR, acknowledging that the medication had been given but not recorded. Facility policy required immediate documentation of medication administration, including PRN medications, specifying the need to record the date, time, dose, symptoms, results, and the signature or initials of the administering staff. Another deficiency occurred when a resident returned from the emergency room with a cranial abrasion and had a dressing applied to the head. The Infection Preventionist (IP) and an LPN evaluated and treated the abrasion, with the IP applying Xeroform and wrapping the resident's head. However, the clinical record for this resident lacked a physician's order for the wound care that was provided. The IP later confirmed that, although verbal approval from the physician had been obtained, the order was not documented in the resident's record as required by facility policy. Both deficiencies were confirmed through observation, interview, and record review. The facility's policies on medication administration and skin integrity required timely and complete documentation of all care provided, including obtaining and recording physician orders for treatments and documenting all medication administrations in the MAR.