Failure to Accurately Document Medication Administration and Resident Care Activities
Penalty
Summary
Staff failed to accurately document medication administration and care activities for multiple residents. For one resident with an order for Ativan (Lorazepam), a controlled substance, the medication administration record showed consistent documentation of administration, but the corresponding controlled drug sheets lacked entries for seven specific dates, indicating no documentation that the medication was removed from supply on those occasions. Despite requests, no additional documentation was provided to account for these discrepancies. In another case, a resident with severe dysphagia and a care plan requiring supervision and assistance during meals was observed feeding themselves unsupervised in bed. The care plan specified that the resident should be out of bed for meals and that any refusals should be documented. However, staff documented that the resident was out of bed for breakfast, contrary to direct observation, and failed to record the resident's refusal to get out of bed. Additionally, documentation for activities of daily living (ADL) was incomplete for several residents. One resident's records had blank spaces for personal hygiene care and repositioning tasks across multiple shifts. Another resident, dependent on staff for total care, reported not receiving a shower for at least two weeks, and observations confirmed poor hygiene. The medical record indicated a shower was given, but the resident denied this, and no supporting shower sheet was found. The DON confirmed the lack of accurate documentation for these care activities.