Failure to Document Medication Administration and Wound Care Treatments
Penalty
Summary
The facility failed to ensure accurate and complete documentation of medication administration and treatment interventions for two residents. For one resident recently admitted after open heart surgery, there was a physician order for Acetaminophen for pain, but the Medication Administration Record (MAR) did not show that the medication was administered during the resident's stay. Interviews with LPNs revealed that although the medication was requested and reportedly given, it was not documented in the MAR, and no pain assessment was completed following the request. The nurse involved later acknowledged the lack of documentation and intended to enter it as a late entry. For another resident with a stage IV pressure ulcer and vascular dementia, review of the MAR and Treatment Administration Record (TAR) showed multiple missed treatments, including the application of off-loading boots and wound care with calcium and silver alginate, on several dates. There was no documentation in the medical record or progress notes to explain the missed treatments. The resident reported concerns about not being repositioned as ordered, and the Director of Nursing confirmed the missed treatments and lack of documentation explaining the omissions.