Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice regarding the administration and documentation of physician-ordered medications and treatments for two residents. For one resident with a history of bipolar disorder, depression, and suicidal ideation, the Medication Administration Record (MAR) indicated that an antidepressant medication was administered on specific dates, but a nurse admitted to falsely documenting the administration when the medication was not actually given. There was also no documentation that the provider was notified of the missed dose, as required by professional standards and facility policy. For another resident with a complex medical history including a right foot amputation, diabetes, and impaired skin integrity, the Treatment Administration Record (TAR) showed multiple omissions in the documentation and completion of wound care treatments as ordered by the physician. Observations revealed that the resident's wound dressing had not been changed for several days, despite documentation indicating otherwise. The wound care nurse confirmed that the dressing had not been changed since a specific date, and the wound was observed to be swollen and at risk of dehiscence. There was no documentation of treatment refusals or provider notification regarding missed treatments. Interviews with nursing staff and the Director of Nursing confirmed that treatments and medications were not administered or documented according to orders and policy. Staff acknowledged that refusals and missed treatments were not consistently documented, and that provider notification did not occur as required. Facility policy and professional nursing standards require accurate documentation and timely communication with providers regarding missed medications and treatments, which was not followed in these cases.