Failure to Accurately Document PRN Medication Administration and Foley Catheter Care
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with professional standards for two residents. For one resident with chronic pain syndrome, the facility did not document the administration of a PRN dose of Tramadol, an opioid analgesic, on the Medication Administration Record (MAR) for a specific date and time, despite evidence from the narcotic book and nurse interview that the medication was given. Additionally, the effectiveness of the PRN Tramadol was not recorded as required by facility policy. The nurse involved acknowledged the omission and confirmed that both the administration and effectiveness should have been documented. For another resident with urinary retention and an indwelling Foley catheter, the facility failed to accurately document the size and care of the catheter. Although physician orders specified a 16 French catheter with a 10 ml balloon, observation revealed the resident had a 14 French catheter in place, and the balloon size was unreadable. The Treatment Administration Record (TAR) indicated that the catheter had been changed to the correct size on multiple occasions, but interviews with nursing staff and the Director of Nursing revealed that the documented catheter changes had not actually been performed, resulting in inaccurate records. These deficiencies were identified through observations, interviews, and record reviews, and were in direct violation of the facility's own policies regarding medication administration and catheter care documentation. The failures involved both the omission of required documentation and the inaccurate recording of care that was not provided.