Failure to Accurately Document Medication Administration and Unavailability
Penalty
Summary
The facility failed to ensure accurate clinical record documentation regarding the administration of Clozapine for one resident diagnosed with Schizophrenia. The resident had an order for Clozapine 25 mg daily, which was to be administered alongside regular lab monitoring. Review of the medication administration record for a specified period showed that the medication was only documented as given on three specific days, with no documentation for the remaining days. Interviews with staff revealed that the medication was not available during this period, and the administration entries for those three days were incorrect, as the medication had not actually been administered. Staff interviews indicated that the facility's protocol requires staff to search for medications in additional storage areas if not found in the designated cart, and to contact the provider and pharmacy if the medication remains unavailable. Staff are also expected to document all actions taken, including communications and directives, in the resident's electronic health record. However, for this resident, there was a lack of accurate documentation explaining the missed doses and the steps taken to address the medication unavailability. The Director of Nursing confirmed that the medication was not available at all during the period in question and that the documentation indicating administration on three days was incorrect. The facility's policy emphasizes the importance of complete and accurate documentation to provide a full account of resident care and to guide providers in prescribing appropriate treatments. The failure to accurately document the administration and unavailability of Clozapine resulted in clinical records that did not correctly reflect the resident's care during the specified timeframe.