Failure to Document Medication and IV Therapy Administration as Ordered
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two patients by not following physician orders and facility policy regarding medication and treatment administration records. For one patient with diagnoses including diabetes mellitus type 2 and chronic pain syndrome, the order summary required monitoring and documentation of episodes of depression, specifically unconsolable crying, while on Zoloft. However, the Medication Administration Record (MAR) for September 2025 showed that this monitoring was not documented, checked, or signed off as performed on multiple dates and shifts. The Director of Nursing confirmed that the required documentation was missing for these periods and acknowledged that such monitoring was necessary to determine the effectiveness of the medication. For another patient with dementia and protein-calorie malnutrition, the order summary required administration of Dextrose Sodium Chloride (D5NaCl) Solution 5-0.45% at a specified rate until the patient consumed more than 50% of food intake. The Intravenous Medication Administration Record (IV MAR) indicated that the administration and documentation of this IV therapy were not completed or signed off on three specific dates. The Director of Nursing confirmed the lack of documentation and stated that the fluids were not documented as administered as ordered. The facility's policies and procedures required adequate monitoring and documentation for both medication and IV therapy, including specifying the type of fluid, rate of infusion, and the signature and title of the person recording the data. The failures in documentation for both patients resulted in incomplete medical records, as confirmed by record review and staff interviews.
Plan Of Correction
Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/25/25, Patient 7 was reassessed following a reported episode of inconsolable crying possibly related to the current antidepressant medication. Upon assessment by the RN Supervisor, no further episodes of inconsolable crying were observed. The physician was notified and reviewed the resident's current medications and behavioral patterns for a 3-month look-back period. Gradual Dose Reduction (GDR) was initiated. - On 09/29/2025, a 1:1 in-service training was conducted with the RN responsible for Patient 9's IV therapy regarding accurate documentation practices, including type of IV fluid, rate of infusion per hour, additives, if and signature and title of the person recording the data. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with antidepressant medication are potentially at risk of being affected. - All residents with IV Hydration, IV medication, and Peripheral Lines are potentially at risk of being affected. - On 10/10/25, the Director of Nursing (DON) conducted a comprehensive audit of all residents with an order for antidepressant medication to ensure accuracy and completeness of behavior monitoring documentation. - No other residents were affected by this deficient practice. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with an order for IV Hydration, IV medication, and peripheral lines. The audit emphasized accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of recording nurse. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - From 10/10/25 to 10/16/25, the Director of Nursing (DON) conducted in-service training for licensed nurses on the facility's medication administration policy and procedure, emphasizing the importance of accuracy and completeness of behavior monitoring documentation. - From 10/10/2025 to 10/16/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted in-service training for licensed nurses regarding the facility's medication administration policy and procedure, emphasizing accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of recording nurse. - Starting 10/16/25, the DON and/or ADON will conduct a random audit 2-3 times per week for 3 months of residents with an order for antidepressant medication to ensure accuracy and completeness of behavior monitoring documentation. - Starting 10/16/25, the DON and/or ADON will conduct a random audit 2-3 times per week for 3 months of residents with IV Hydration, IV medication, and residents with peripheral lines. The audit will emphasize accurate documentation practices, including identification of IV fluid type, infusion rate (mL/hour), additives if applicable, and the signature name and title of the recording nurse. - Any findings identified during the audits will be addressed promptly, and reeducation will be provided as necessary. A summary of each audit will be submitted to the DON and ED for review and follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained: - The DON and/or ADON will report the results of the monitoring to the QA committee monthly for 3 months for review and recommendations, ensuring substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root causes and develop an action plan to prevent any further deficient practices.