Failure to Monitor and Document Medication Indications and Side Effects
Penalty
Summary
The facility failed to ensure that residents' drug regimens were adequately monitored and free from unnecessary drugs for several residents. For one resident, there was no diagnosis provided for the use of an antianxiety medication, Lorazepam, despite multiple as-needed orders for varying dosages. The resident's care plan and medication administration records did not indicate a diagnosis of anxiety or agitation, nor was there documentation in the Minimum Data Set (MDS) to support the use of an antianxiety medication. Another resident was prescribed Doxycycline, an antibiotic, without a related diagnosis such as MRSA being documented in the physician's order or medication administration record. Although the resident had a chronic wound with a history of MRSA, the specific indication for the antibiotic was not included in the order. Additionally, this resident, along with two others, was receiving anticoagulant therapy, but there was no evidence of monitoring for side effects such as abnormal bleeding or bruising in their treatment administration records. Interviews with nursing staff and the Director of Nursing (DON) confirmed that there was no specific process or documentation in place for monitoring side effects of anticoagulant medications. Staff stated that while they visually observed residents for signs of bleeding or bruising, there was no formal order or designated area in the records for documenting such monitoring. Facility policy required that each resident's medication regimen be managed and monitored for indications, clinical need, and adverse consequences, but these requirements were not met for the residents reviewed.