Failure to Accurately Document Medication Administration and Wound Care
Penalty
Summary
The facility failed to accurately document medication administration and wound care for two residents, resulting in deficiencies related to falsification and improper record-keeping. For one resident with diagnoses including metabolic encephalopathy and intractable epilepsy, a medication pass observation revealed that medications scheduled for 9:00 AM were administered after 11:00 AM. Despite this, the Medication Administration Record (MAR) reflected that the medications were given at the scheduled time and were documented with the initials of a nurse who did not actually administer the medications. Interviews with nursing staff and management confirmed inconsistencies in documentation, with staff unable to clarify whose initials were used and who actually provided the care. Another resident with impaired skin integrity and a history of diabetes, obesity, and hemiplegia was found to have incomplete and inaccurate documentation regarding wound care. The care plan required regular application of Silvadene cream to the resident's buttocks and ischium area. Observations and interviews revealed that a Certified Nursing Assistant (CNA) applied the cream, although the order specified that a licensed nurse should perform this task. The Wound Care Nurse and other staff provided conflicting accounts of who applied the treatment, and the MAR indicated that the Wound Care Nurse had signed for treatments she did not perform. Additionally, required skin assessments and progress notes were missing from the resident's record for the relevant dates. These deficiencies were identified through policy review, record review, direct observation, and staff and resident interviews. The facility's failure to ensure accurate and truthful documentation of care provided, as well as to maintain complete medical records in accordance with professional standards, led to findings of falsified documentation and improper record-keeping for both medication administration and wound care.