Failure to Accurately Document Medication and Safety Device Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the medication administration record (MAR) and treatment administration record (TAR) for two residents. For one resident with chronic obstructive pulmonary disease, congestive heart failure, an indwelling urethral catheter, and neuromuscular dysfunction of the bladder, the MAR was left blank for scheduled doses of intravenous meropenem, an antibiotic ordered for a urinary tract infection. Interviews with nursing staff and the Director of Nursing confirmed that the MAR was not signed for these doses, and staff could not verify whether the medication was administered, despite facility policy requiring complete and accurate documentation. For another resident with multiple diagnoses including COPD, diabetes, dementia, and psychiatric disorders, the TAR was not signed to indicate that required safety devices—a seat belt and pressure alarm—were checked as ordered. Observations and interviews revealed that these devices were not in place as ordered, and staff could not specify when or why they were removed. Additionally, there was no documentation in the progress notes regarding the removal of these devices, despite ongoing documentation on the TAR indicating they were checked and in place.
Plan Of Correction
Resident #43 and #25 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #43 MAR was immediately updated. Resident #25 seat belt and chair alarm was immediately DCed by DON. Education provided to all staff by DON on 5/22/25 regarding appropriate and timely documentation. MAR and TAR reviewed on randomly selected residents 5/28/25 by IDT during Risk to ensure timely and accurate documentation. DON/Designee to audit 2 MAR and 2 TAR weekly for 4 weeks to ensure accurate documentation. Results to be reviewed in QAPI.