Failure to Accurately Document Medication Administration and Assessments
Penalty
Summary
The facility failed to ensure accurate and complete documentation of a resident's Medication Administration Record (MAR) for one resident. The resident, who had multiple diagnoses including bipolar disorder, PTSD, fibromyalgia, major depressive disorder, anxiety disorder, legal blindness, insomnia, and type 2 diabetes requiring long-term insulin use, had several physician orders for medications, behavioral monitoring, and clinical assessments. These orders included administration of various medications such as oxycodone-acetaminophen, trazodone, duloxetine, insulin, Jardiance, Prozac, gabapentin, and promethazine, as well as regular monitoring for side effects, pain, behavioral symptoms, and vital signs. Review of the resident's MAR for April and June revealed multiple instances where medication administration and required assessments were not documented as completed. Specific omissions included missing documentation for insulin injections, oral medications, behavioral and side effect monitoring, pain assessments, and vital sign checks across several shifts and dates. These gaps were identified for both scheduled and as-needed medications, as well as for required clinical observations and interventions. Interviews with nursing staff and the Director of Nursing confirmed that the medications, assessments, and observations in question should have been documented but were not. The staff members responsible for the resident's care on the identified dates acknowledged the lack of documentation, and the Director of Nursing verified the omissions upon review of the MARs for the relevant months.