Incomplete Documentation of Medication and Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents regarding the documentation of medications and oxygen administration. For one resident with diagnoses including heart failure, chronic pulmonary edema, and hypertension, the medical record review revealed missing documentation for the administration of BiPAP, oxygen therapy, and several prescribed medications on specific dates and times. The resident's care plan required continuous oxygen and BiPAP use at bedtime and during naps, with instructions to chart refusals, but the Medication Administration Records (MARs) lacked entries for these interventions. The Director of Nursing was unable to provide any additional documentation to account for the missing records. Another resident, diagnosed with Alzheimer's disease, COPD, and chronic respiratory failure with hypoxia, also had incomplete MARs. The records showed that prescribed inhalers and nebulizer treatments were not documented as administered on several occasions. The care plan required administration of aerosol or bronchodilators as ordered, but the MARs for June and July were missing entries for specific medications at scheduled times. The Director of Nursing confirmed that no further information was available to explain the missing documentation.