Failure to Accurately Document Medical Treatments and Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for two residents. For one resident with respiratory failure, COPD, obesity, and emphysema, a physician's order required the use of an auto-pap device as needed for naps and every night. The treatment record indicated the device was administered on two specific evenings; however, a self-reported incident and subsequent interviews revealed that the auto-pap was not actually applied on one of those nights. The nurse responsible could not provide a reason for not administering the treatment and had signed off as if it had been completed. For another resident with sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease, there was a physician's order for an antibiotic to be administered twice daily. Documentation showed the medication was not available at the time it was needed, and although it was later pulled from the starter kit, there was no record of the time or signature of the nurse who retrieved it. The medication administration record noted the antibiotic was not given and referred to a nurse's note, but there was no documentation confirming administration. Interviews with the DON and a unit manager confirmed the lack of required documentation.