Failure to Document Medication and Treatment Administration in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, a registered nurse (RN) did not document the administration of physician-ordered medications and treatments for a resident during her assigned double shift. Review of the resident's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for the specified date showed missing initials and lack of documentation for multiple required treatments, including tracheostomy care, wound care, nebulizer treatments, aspiration precautions, and vital sign monitoring. There was also no progress note or other nursing documentation indicating that the care and medications were provided on that day. The resident involved was a male with severe cognitive impairment and total dependence for activities of daily living. His medical history included hypertension, neurogenic bladder, diabetes, Parkinson's disease, respiratory failure, anoxic brain damage, and a history of tracheostomy and G-tube feeding. He required frequent and complex care interventions, such as suctioning, oxygen therapy, skin care, and regular monitoring for signs of aspiration and infection. Despite these needs, the required documentation to confirm that these interventions were performed was absent for the identified shift. Interviews with facility staff revealed that the RN believed she had provided the care but attributed the lack of documentation to possible technical issues with the new electronic medical record (EMR) system. Other staff, including the Director of Nursing (DON) and the Weekend Supervisor, were unaware of the missing documentation until after the fact. The facility's own policies required that all care, medications, and treatments be documented in the resident's medical record, including the date, time, and details of the care provided. The absence of this documentation meant there was no verifiable record that the resident received the necessary care and treatments as ordered.