Failure to Properly Document and Transcribe Standing Order Medication Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice for documentation were followed during the transcription and administration of a standing order medication, specifically bacitracin ointment, for two residents with wounds. The standing order for bacitracin required that it be transcribed into the resident's medication administration record (MAR) with all necessary details, including the prescribing practitioner's name, medication name, dosage, route, frequency, duration, and indication for use. However, for both residents, the administration of bacitracin was documented in progress notes but not properly transcribed or documented in the MAR or electronic health record (EHR) as required by facility policy and professional standards. For the first resident, who had a history of schizoaffective disorder and sustained multiple self-inflicted burns and other minor wounds, bacitracin was applied on several occasions as documented in progress notes. Despite this, there was no corresponding order or documentation in the MAR or EHR specifying the use of bacitracin, nor were the required elements of a complete medication order present. Nursing staff confirmed that the standing order for bacitracin should have been transcribed into the MAR and EHR, but this was not done. The facility's process relied on a general standing order in the physician orders, without individual transcription upon use, which led to incomplete documentation and lack of clarity regarding the administration of the medication. For the second resident, who sustained a burn to the finger, bacitracin was also applied and documented in progress notes prior to the transcription of a wound care order into the MAR. The MAR did not include all required elements of the bacitracin order, and the wound care order did not specify the seven-day limit as required by the standing order. Interviews with nursing staff and the DON revealed that the facility practice was not to transcribe individual standing orders into the MAR or EHR unless specifically utilized, and that documentation of administration was often limited to progress notes rather than the MAR. This practice resulted in incomplete and inconsistent documentation of medication administration, failing to meet professional standards and facility policy.