Failure to Document Resident Agitation and Medication Administration
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, a Licensed Vocational Nurse (LVN) did not document a progress note or nurse note regarding a resident's increased agitation on a specific date, despite administering Ativan for anxiety. The Medication Administration Record (MAR) indicated that the medication was given, but there was no corresponding documentation in the electronic health record (EHR) about the resident's condition or the administration of the medication. The resident involved was an elderly female with diagnoses including anxiety disorder, heart disease, and kidney disease. Her care plan required monitoring and recording of behavioral or mood problems, as well as the effectiveness of psychotropic medications. Facility policy required documentation of all services provided, changes in condition, and medication administration. During interviews, staff confirmed that documentation should have occurred for the resident's increased agitation and the administration of Ativan, but this was not completed.