Incomplete Medication Documentation and Missing Administration Parameters
Penalty
No penalty information released
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Summary
The facility failed to ensure complete and accurate medical record documentation for a resident with diagnoses including diabetes and heart failure. A physician's order for Droxidopa every 8 hours was present, but the April Medication Administration Record (MAR) had blank documentation boxes for three scheduled doses, despite the Assistant Director of Nursing stating the medication was administered but not recorded. Additionally, a physician's order for Midodrine every 8 hours as needed for hypotension lacked specific blood pressure parameters for administration, and the Director of Nursing confirmed that no such parameters could be found in the record.