Failure to Accurately Document Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication and treatment administration for multiple residents, as evidenced by blank entries on Medication Administration Records (MAR) and Treatment Administration Records (TAR). For one resident with encephalopathy and a tracheostomy, required trach care and inner cannula changes were not documented on several shifts, despite physician orders for these treatments to be performed every shift. Nursing staff confirmed that these treatments should have been performed and documented, but the records were left blank on specific dates. Additional residents with diagnoses such as anxiety, depression, GERD, dementia, diabetes, atrial fibrillation, osteoporosis, and congestive heart failure also had blank entries for various medications on their MARs. These included missed documentation for medications such as Gas-X, Pantoprazole, Famotidine, Levothyroxine, Sodium Chloride, Guaifenesin, Wellbutrin, Metformin, Cipro, and Amoxicillin. Interviews with nursing staff and the DON revealed uncertainty about the reasons for the blank entries, with explanations ranging from possible computer errors to shift change issues, but no definitive cause was identified. Facility policy requires that the MAR be initialed by the person administering the medication, but this was not consistently done.