Failure to Document Reasons for Missed Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting the reasons why prescribed medications were not administered. For each resident, Alprazolam was ordered by the physician to address anxiety, but the medication was not given on multiple occasions. The Medication Administration Record (MAR) indicated a chart code requiring further explanation in the nurses' notes, but no such documentation was found in the progress notes for any of the residents. Additionally, there was no evidence that the physician was notified about the unavailability of the medication. Resident #9, with multiple diagnoses including anxiety disorder, depression, hypertension, and chronic obstructive pulmonary disease, did not receive Alprazolam as ordered on several days. Staff interviews confirmed that the medication was not available and that staff did not document the reason for non-administration or notify the physician. Similarly, Resident #10, who had chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder, also did not receive Alprazolam as ordered, and staff again failed to document the reason or notify the physician. Resident #7, with a complex medical history including multiple fractures, chronic heart failure, and anxiety disorder, experienced the same issue, with multiple missed doses of Alprazolam and no corresponding documentation or physician notification. The facility's policy required that any withheld, refused, or unavailable medication be documented in the nurses' notes with an explanatory note and that the physician be notified, with the notification and response documented. Despite this policy, staff interviews and record reviews confirmed that these steps were not followed for the three residents, resulting in incomplete and inaccurate medical records regarding medication administration.