Failure to Document Medication Administration and Follow-Up on Prescriptions
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents by not ensuring proper documentation of medication administration or refusal on the Medication Administration Record (MAR) for multiple residents. For one resident with complex medical conditions including acute kidney failure, diabetes, and pressure ulcers, staff did not document the administration or refusal of several prescribed medications, such as anticoagulants, antidepressants, pain medications, gastrointestinal treatments, potassium supplements, and muscle relaxants, over several days. Interviews with staff revealed uncertainty about the reasons for missing documentation, with some staff indicating the resident was noncompliant or out of the facility, but these events were not properly recorded on the MAR as required by facility policy. Another resident, who had diagnoses of diabetes and morbid obesity, attended an outside dermatology appointment and reportedly received a new prescription for a topical medication. The resident reported discomfort and lack of access to the prescribed cream, stating that staff had not applied it and were unaware of its status. Interviews with nursing staff indicated a lack of follow-up with the outside provider and pharmacy to obtain the prescription, and there was no documentation of these follow-up attempts in the resident's progress notes. The Director of Nursing and other staff confirmed that the expected process was not followed, and the medication was not obtained or administered in a timely manner. A third resident with diagnoses including acute post-hemorrhagic anemia, diabetes, colon cancer, and atrial fibrillation also experienced multiple instances where staff failed to document the administration or refusal of several medications, including blood thinners, diabetes medications, gastrointestinal treatments, nerve pain medications, antidepressants, and antihypertensives. Staff interviews consistently indicated that all medications administered or refused should be documented on the MAR, and that blank areas on the MAR are not acceptable. The Director of Nursing and Administrator both confirmed that lack of documentation means the medication was not given, and that staff are expected to document all medication administration or refusals.