Failure to Accurately Document and Administer Medications per Physician Orders
Penalty
Summary
Nursing staff failed to properly document and administer medications according to physician orders and facility policy for four out of five residents reviewed. During medication administration, an LPN was observed preparing a medication dose that did not match the physician's order in the electronic Medication Administration Record (eMAR). The LPN administered the medication and then signed the eMAR for a different dose than what was actually given. When questioned, the LPN admitted to signing for the incorrect dose and expressed confusion during the process. For multiple residents, review of the Medication Administration Records (MARs) revealed missing nurse signatures for scheduled medication administrations, indicating that medications may not have been given or were not properly documented. Progress notes for these residents did not contain any documentation to support that the medications were administered at the scheduled times. Interviews with staff confirmed that medications are expected to be signed out on the MAR immediately after administration, and that blank spaces on the MAR indicate either an omission or a refusal, which should be documented accordingly. The facility's policy on medication administration requires verification of the pharmacy prescription label against the MAR, confirmation of the correct medication, dose, and time, and immediate documentation of administration on the MAR. Despite this, the observed practices and record reviews showed that these procedures were not consistently followed, resulting in incomplete or inaccurate medication records for several residents with various medical diagnoses and cognitive statuses.
Plan Of Correction
F755 - Pharmacy Srvcs/Procedures/Pharmacist/Records Element 1: Corrective Actions Based on observation, interview, and review of the facility documents it was identified for residents #2, #3, #4, and #5 that the facility failed to accurately document medication administration. On 4/22/25, the Director of Nursing initiated re-education to the nursing staff on the Policy and Procedure Medication Administration. On 4/23/25, the facility initiated an audit to monitor for the administration of medication in accordance with physician orders. Element 2: Identification of at-Risk Areas All residents have the potential to be affected by the same practice. Element 3: Systemic Change The Assistant Director of Nursing (ADON) re-in-serviced the nursing staff on the Policy and Procedure for Medication Administration. The Director of Nursing/designee will audit and monitor 3 residents' charts to check for compliance with Medication Administration policy and procedure weekly times four (4), then and after the 4-weeks and competency is established, the facility will continue auditing 3 charts monthly for one (1) quarter, to monitor for compliance and report to QA. Element 4: Monitoring/Quality Assurance On 4/22/2025, the facility initiated a QAPI - Performance Improvement Project identifying any non-compliance with Medication Administration. The facility's goal is to ensure that all protocols are followed.