Medication Documentation and Administration Deficiencies
Penalty
Summary
The facility failed to properly document the administration of acetaminophen for a resident who was admitted with pneumonia and sepsis and had moderately impaired cognition. On a specific date, the resident experienced a fever and was given acetaminophen as needed, which successfully reduced the fever. However, the administration of this medication was not recorded in the Medication Administration Record (MAR), as confirmed by the nurse who stated they forgot to document it. The Director of Nursing acknowledged that this lack of documentation could lead to duplicate administration and potential adverse reactions. There were also discrepancies in the accountability records for controlled medication, specifically tramadol, for another resident with severe cognitive impairment and multiple contractures. The facility's records, including the Individual Narcotic Record and prescription labels, did not match the physician's order for tramadol dosing. The narcotic records were handwritten and contained incorrect information regarding the dosage and administration times, which did not align with the pharmacy label or the physician's order. The Director of Nursing confirmed that the information on the narcotic count sheet should match exactly with the pharmacy label and that manual transcription increases the risk of medication errors. Additionally, the facility did not ensure that a resident with Parkinson’s disease, diabetes, and other conditions received lactulose as ordered for constipation. The resident reported not having a bowel movement for more than a week, and documentation confirmed a gap of several days without a bowel movement. The nurse acknowledged that the resident should have been offered lactulose during this period, as per the physician's order. The Director of Nursing stated that medications should be administered as ordered, and the facility's policy required medication administration according to orders.