Failure to Administer and Document Medications and Treatments per Professional Standards
Penalty
Summary
Facility staff failed to provide services in accordance with professional standards of practice for two residents. For one resident, who was admitted with pneumonia and sepsis and required IV antibiotics via a PICC line, staff did not consistently administer IV cefazolin at the ordered times, with several doses given between 3 to 6.5 hours late. Additionally, staff did not document required measurements of the PICC line external length and arm circumference upon admission or with scheduled dressing changes, despite signing off that these tasks were completed. There were also missed or undocumented tasks related to monitoring the IV site for infection, administering and documenting oxygen therapy, and changing IV tubing as ordered. For another resident with diagnoses including depression and atrial fibrillation, there were multiple instances where staff left blank documentation boxes on the MAR and TAR for ordered medications, supplements, and required monitoring. These included missed documentation for administration of high calorie/protein supplements, Eliquis, and monitoring for side effects of antidepressant and antipsychotic medications, as well as documentation of target behaviors related to insomnia and major depressive disorder. Staff confirmed that blank boxes indicated the task was either not done or not documented, and that all medications and treatments should be documented upon administration. Interviews with facility staff, including the Resident Care Manager and Director of Nursing, confirmed that the expectation was for nurses to administer medications and perform treatments as ordered, and to only sign for tasks that were actually completed. The lack of documentation and inconsistent administration of medications and treatments were acknowledged by staff as not meeting professional standards of practice.