Failure to Document Resident's Self-Administration of Home Medications
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, specifically regarding medications brought from home and self-administered by the resident. Upon admission, the resident did not have access to all prescribed medications through the facility, leading the resident to request that their spouse bring pain medication and insulin from home. The resident independently administered these medications, but this was not documented in the medical record. Nursing progress notes lacked documentation of discussions about available medications, and there was no record of the physician being notified that the resident took their own medications due to the delay in pharmacy delivery. Interviews with staff revealed that the resident was offered insulin from the facility's supply but chose to use their own, and that the facility did not have the resident's narcotic medication available until a later pharmacy delivery. The Director of Nursing and LPNs involved confirmed that the administration of home medications was not fully documented in the electronic medical record. The facility's policy requires that all services provided, changes in condition, and resident responses be documented objectively and completely, which was not followed in this instance.