Failure to Accurately Administer and Document Medications and Assessments
Penalty
Summary
The facility failed to ensure accurate administration and documentation of medications, weekly skin assessments, pain and behavior monitoring, and blood pressure checks as ordered by physicians for two residents. For one resident, who was cognitively intact and had diagnoses including anxiety, depression, asthma, and thyroid disorder, there were discrepancies between the controlled drug log and the Medication Administration Record (MAR) regarding the administration of alprazolam (Xanax). The records showed multiple instances where doses were either not signed out, marked as refused or held without corresponding documentation, or left blank, with no progress notes explaining the omissions. The resident reported not always receiving medications as prescribed, particularly during a hospital transfer, and there was no documentation to clarify whether medications were refused, held, or not administered. For another resident with severe cognitive impairment, multiple dependencies for activities of daily living, and diagnoses such as hypertension, hyperlipidemia, stroke, hemiplegia, dementia, and depression, the MAR and Treatment Administration Record (TAR) revealed several missed or undocumented opportunities for medication administration, pain assessments, skin checks, behavior monitoring, and blood pressure monitoring. Numerous entries were left blank, indicating that either the care was not provided or not documented, with no codes or progress notes to explain the omissions. Orders for artificial tears, senna-docusate, atorvastatin, and routine assessments were not consistently documented as completed. Interviews with staff, including an LPN and the DON, confirmed that all medications and treatments should be documented at the time of administration, and that blanks on the MAR or TAR indicate a failure to document or administer as required. The DON stated that the MAR and control log should match, and any refusals or omissions should be clearly coded and explained in the progress notes. The facility's policies require timely and accurate documentation of all care provided, but these were not followed, resulting in incomplete records and unverified administration of ordered care.