Failure to Document Medication and Feeding Administration
Penalty
Summary
Facility staff failed to document the administration of medications for three residents, as required by the facility's medication administration guidelines. The guidelines specify that medications must be given as prescribed and promptly recorded in the medical record by the person administering them. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke, seizure disorder, depression, cerebral palsy, and anxiety, staff did not document the administration of several medications, including anti-seizure drugs, antidepressants, and vitamin supplements, across multiple dates in March, April, and May. Another resident, cognitively intact and diagnosed with diabetes, had undocumented administration of insulin on several occasions, particularly on weekends, and reported not receiving insulin doses unless requested. A third resident, also cognitively intact with ALS and a feeding tube, had undocumented administration of tube feedings on several dates, with the resident reporting missed feedings on weekends. Interviews with the DON and the administrator confirmed awareness of complaints regarding a weekend nurse not administering or documenting medications, with the DON stating that issues had been reported to administration but was unsure if any action had been taken. The administrator acknowledged concerns with the weekend nurse and emphasized the expectation that staff follow physician orders and document medication administration, stating that if it is not documented, it is considered not done.