Lack of Documentation for PRN Medication Administration in Hospice Resident
Penalty
Summary
The facility failed to ensure that as-needed (PRN) medications were administered with proper documentation of the specific indication for use for a resident receiving hospice care. The resident, who had multiple diagnoses including stroke, dysphagia, chronic kidney disease, quadriplegia, vascular dementia, and heart failure, was cognitively impaired and at risk for pain as noted in the care plan. Physician orders were in place for Lorazepam for anxiety, restlessness, and insomnia, and for Morphine Sulfate for pain or shortness of breath, both to be given as needed. The Medication Administration Record showed that both medications were administered on several occasions. However, the nurses' notes did not consistently document the specific reason or indication for administering these medications prior to their use. In several instances, there was no documentation that the resident had experienced pain, anxiety, or restlessness before receiving the medications, nor was there an explanation for administering both medications at the same time. The Director of Nursing was unable to provide additional information regarding the lack of documentation. This deficiency was identified during a complaint investigation.