Failure to Document PRN Medication Administration and Effectiveness
Penalty
Summary
Staff failed to properly document the administration of a PRN medication and did not follow up to assess its effectiveness for a resident with Parkinson's Disease, coronary artery disease, and diabetes mellitus. The resident, who was frequently incontinent and required moderate assistance with activities of daily living, had an active order for milk of magnesia as needed for constipation. Review of the Medication Administration Record (MAR) showed that the medication was not signed out as given during the period it was ordered. Staff interviews revealed uncertainty about when the medication was administered and whether its effectiveness was evaluated, with the nurse responsible unable to recall the specific day or if documentation was completed. Further interviews with CNAs indicated that the resident did not have a bowel movement as expected and exhibited changes in condition, which were reported to the nurse. The facility's bowel policy required nurses to assess residents who had not had a bowel movement, document findings, and follow up on PRN medication effectiveness, but these steps were not followed. The Director of Nursing confirmed that nurses are expected to document administration and effectiveness of PRN medications, but this was not done in this case.