Medication Documentation and Return of Personal Medications Deficiencies
Penalty
Summary
Nursing staff failed to properly document medication administration for two residents. In one case, a nurse did not administer a prescribed diclofenac gel for pain management to a resident for at least two weeks, yet the Medication Administration Record (MAR) indicated all doses were given, with no documentation of missed or refused doses. The Director of Nursing (DON) confirmed that the MAR should have been annotated if the medication was not administered, but the required documentation was absent. In another instance, the administration of a controlled substance (Dilaudid) was not documented for a resident, and the DON acknowledged that the nurses forgot to record the administration on the MAR, contrary to facility policy requiring immediate documentation after each medication is given. Additionally, the facility failed to return home medications brought in by a discharged resident. Twelve oral syringes of lorazepam, a controlled substance, were found stored in a locked drawer for disposal, even though these were personal medications that should have been returned to the resident or their family upon discharge. The DON stated there was no facility policy on handling home medications at discharge, and the existing personal property policy did not address this situation.