Failure to Document and Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure proper documentation and administration of medications and treatments for two patients, resulting in deficiencies related to medication and treatment records. For one patient with chronic respiratory failure, asthma, and pleural effusion, the treatment nurse did not sign the electronic Treatment Administration Record (eTAR) for three ordered treatments on a specific date. The treatments included care for a right thigh scab, a right Pleur X catheter, and a post-surgical spine site. The eTAR was left blank for these treatments, while other dates were properly signed, indicating a lapse in documentation and uncertainty about whether the treatments were administered as ordered. In another instance, a cognitively intact patient with paraplegia and multiple medication orders did not receive their scheduled morning medications at the prescribed time due to refusal. The nurse documented the medications as given before actually administering them, which did not occur until later in the afternoon. This premature documentation could have led to confusion for the oncoming shift and the risk of medications being administered too close together. The nurse acknowledged documenting before administration and recognized the potential for confusion and medication errors. Both deficiencies were confirmed through interviews with nursing staff and review of facility policies, which require that medications and treatments be documented immediately after administration. The facility's policies also emphasize the importance of accurate and timely documentation to ensure continuity of care and adherence to physician orders. The failure to follow these procedures resulted in incomplete records and the potential for missed or improperly timed treatments and medications.
Plan Of Correction
Completed patient 2's treatment on 10/04/2025, immediately completed late entry documentation. On 10/07/2025, the RN supervisor immediately assessed Patient 5 for any change of condition or abnormality of vital signs: BP = 131/74, P = 80, R = 18, O2 Sat = 96%, and Pain level = 0/10. Patient 5 was stable with no signs of distress and remained alert/oriented x 4, able to verbalize needs with no problem. MD was notified. On 10/7/2025, the DON initiated and completed a one-on-one in-service with LVN 4 to discuss the policy and procedure (P/P) on charting and documentation and timely medication administration. The emphasis was on signing eTAR immediately upon completion of treatment. DON also discussed the potential of unwanted effects from medications being administered too close to the time of the next ordered dose to be given. DON reiterated the importance of notifying the patient's MD of circumstances that lead to the delayed medication administration. Any MD orders will be written and carried out; a 72-hour monitoring period would be done to ensure patient safety, followed by accurate timely documentation. **B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE:** 1. On 10/7/2025, upon identification of deficient practice, DON, ADON, and Treatment Nurse immediately reviewed all eTARS for the last 30 days to ensure that no additional gaps in documentation were identified. No additional residents were affected by the deficient practice. 2. On 10/7/2025, DON, ADON, and RN Supervisor immediately interviewed all the licensed nurses on shift to identify any other delayed medication administration. No further residents were identified to be affected by the deficient practice. 3. The Medical Records Department will continue to do daily treatment audits to ensure that any potential deficient practice does not occur by notifying the DON/Designee immediately. Further, the DON has in-services scheduled for licensed nurses for continuous education and training. **C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR:** 1. On 10/28/2025, DON completed an in-service for all nursing staff on "Charting and Documentation" policies and procedures. The discussion was followed by a question-and-answer evaluation. On 10/30/2025, the facility implemented a weekly eTAR audit to be completed by the Medical Records Department to ensure accuracy and completion of treatment documentation. Audit findings will be provided to DON and/or Designee. 2. On 10/30/2025, the facility implemented a medication pass audit that will be completed weekly at random by the DON, ADON, and/or designee to monitor Charge Nurses' medication administration performance on proper and accurate medication administration. Any noted deviations will be corrected immediately, and continued mentoring and performance improvement plans will be implemented as needed. **D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED:** The DON/Designee will report weekly findings for eTAR audits and medication pass audits to the QAPI/QAA committee monthly for three months for recommendations. **E) COMPLETION DATE:** 10/31/2025