Failure to Document Physician Order and Medication Administration
Penalty
Summary
A deficiency occurred when a physician's order for ondansetron, a medication used to prevent nausea and vomiting, was not entered into the electronic medical record for a resident who was admitted for surgical aftercare following digestive system surgery. On the morning in question, a nurse was notified by a family member that the resident was vomiting and feeling nauseous. The nurse contacted a physician and received a verbal order for ondansetron, which was documented in a nursing progress note. However, there was no entry of this order in the electronic medical record, nor was there documentation of the medication's administration on the medication administration record (MAR) during the resident's stay. Interviews with nursing staff revealed that the nurse who received the order could not recall if the medication was actually administered and could not explain the lack of documentation. The nurse who took over the medication cart was informed that the order had been obtained and the medication administered, but there was still no documentation to support this. The physician involved did not recall giving the order but stated that any verbal order should be documented and implemented. The Director of Nursing confirmed the absence of documentation in the electronic medical record and MAR, and stated that proper documentation is expected for continuity of care and monitoring.