Incomplete Documentation of Safety Device Use and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to documentation of safety devices and medication administration. For one resident with severe cognitive impairment and a history of wandering, the care plan required the use of a wander guard device to mitigate elopement risk. Despite this, documentation on the Treatment Administration Record (TAR) indicated the resident was wearing the device, even though direct observation and staff interviews confirmed the device was not in place. A nurse admitted to marking the TAR as if the device was present without verifying, and the device had been removed by the resident the previous night. In another case, a resident with multiple complex medical conditions, including a recent surgery and ongoing IV antibiotic therapy, did not have timely documentation of cefazolin administration on the Medication Administration Record (MAR). The Assistant Director of Nursing (ADON) administered the medication but failed to document it at the time of administration, instead entering a late note in the nursing progress notes several days later. The ADON acknowledged the omission and explained the circumstances, including a delay in entering the order and obtaining the medication from the backup supply. Both incidents were confirmed through record review, staff interviews, and direct observation. Facility policies required accurate and timely documentation of both safety device use and medication administration, but these were not followed in the cases described. The lack of accurate documentation could result in improper care or lack of awareness of residents' needs, as evidenced by the events described in the report.