Failure to Accurately Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents in relation to medication administration. For one resident prescribed metoprolol with specific parameters to hold the medication if systolic blood pressure was less than 110 or heart rate below 60 BPM, the Medication Administration Record (MAR) did not include documentation of the resident's heart rate or blood pressure prior to administration on multiple occasions. Nursing staff reported that vital signs were sometimes entered later or marked as 'NA' as a placeholder, contrary to facility expectations and policy, which require documentation of vital signs before administering cardiac medications. For another resident with physician orders for intravenous sodium chloride solution three times a week for acute kidney injury and dehydration, the MAR indicated the IV fluid was administered, but observation and staff interviews revealed the IV was not actually given as ordered. Staff noted that sometimes IV fluids were started earlier than ordered, or not at all, and the Unit Manager confirmed that the IV fluid was not hung as documented. Facility policies require medications and services to be administered and documented as prescribed, but these requirements were not met in these cases.