Failure to Document Staff Identification on Medication Administration Records
Penalty
Summary
Licensed nursing staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of four sampled residents. Specifically, the Medication Administration Records (MARs) for these residents were missing the required initials and signatures of the licensed staff responsible for administering medications. This omission was observed throughout the month of April for multiple medications, with only a few exceptions where staff signatures or initials were present. Resident 1, who was admitted with diagnoses including hypertension and end stage renal disease, had a MAR for Apixaban administration that lacked staff identification for nearly the entire month. Resident 2, admitted with type two diabetes mellitus, hypertension, and benign prostatic hyperplasia, had MARs for Aspirin and Flomax that also lacked staff initials and signatures for the documented administration dates. Resident 3, with a history of transient ischemic attack, peripheral vascular disease, and glaucoma, had MARs for Dorzolamide-Timolol and Losartan Potassium that were missing staff identification for most of the month, except for one date. During interviews and record reviews, multiple nursing staff, including RNs and LVNs, acknowledged the deficiency and confirmed that it is standard practice to document initials and signatures on the MAR after medication administration. The interim DON also confirmed that the MARs were missing identifiable information for the responsible licensed staff, which is not in accordance with standard practice. The facility's policy and procedures require that orders and documentation be consistent with principles of safe and effective order writing, including the use of approved abbreviations and symbols.