Failure to Accurately Document Medication Administration and Pressure Wound Notifications
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, specifically regarding the documentation of narcotic pain medication administration and the notification of responsible parties and physicians about pressure wounds. For one resident with chronic pain, there were multiple instances where narcotic medications, including Hydrocodone/Acetaminophen and oxycodone, were signed out and administered as indicated on the controlled drug declining count sheets, but these administrations were not documented on the Medication Administration Record (MAR) for several dates across multiple months. Medication aides and nurses involved in administering these medications either did not sign the MAR or believed it was someone else's responsibility, resulting in incomplete medical records for controlled substances. Another resident was admitted with Stage 2 pressure wounds, but the admission progress note did not indicate that the responsible party or physician was notified of these wounds. The nurse who completed the admission note confirmed that no notification was made. Subsequent pressure injury assessments documented that the responsible party and physician were notified of more severe wounds, but the nurse who completed these assessments later stated that she had not actually made the notifications and had documented them in error, assuming others had already done so. Interviews with staff, including medication aides, nurses, and the Director of Nursing, confirmed that there were misunderstandings and lapses in responsibility regarding proper documentation on the MAR and in the notification process for pressure wounds. The Director of Nursing acknowledged that documentation should be accurate and complete, including both medication administration and notifications related to pressure injuries.