Failure to Adhere to Medication Administration and Catheter Care Standards
Penalty
Summary
The facility failed to administer medication according to physician's orders and did not ensure proper care and documentation for a midline catheter site, as required by professional standards. For one resident with a diagnosis including malignant neoplasm of the left renal pelvis and urinary retention, the medical record review showed that several doses of lidocaine hydrochloride gel, ordered for topical application twice daily, were not signed off as administered on the Medication Administration Record (MAR). Interviews with the LPN/Unit Manager and the Director of Nursing confirmed that the absence of documentation indicated the medication was not given, and there was no alternative documentation to support administration of the missed doses. In another case, a resident with chronic respiratory failure, anoxic brain damage, and neurogenic bladder had a peripherally inserted catheter (PIC) in the left forearm. Observation revealed the dressing was not labeled or dated as required. Review of the Treatment Administration Record (TAR) showed that the dressing change and site check orders were not consistently documented, with missing signatures on the TAR and an undated dressing at the time of observation. The Infection Preventionist and DON both stated that dressings should be dated to prevent infection and ensure proper treatment completion. Facility policies reviewed by the surveyor required that medications be documented as administered or withheld, and that IV dressings be labeled with the date and time of change. The failures identified were confirmed through interviews and record reviews, with staff acknowledging the lack of documentation and adherence to policy in both medication administration and catheter site care.