Failure to Accurately Document Medication Administration and Cognitive Status
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident with complex medical needs, including a history of extreme prematurity, chronic respiratory failure with tracheostomy, ventilator dependence, and liver transplant status. On the date in question, the resident was scheduled to receive tacrolimus, a critical immunosuppressive medication, at 9 a.m. The Medication Administration Record (MAR) for that time was left blank, and there was no contemporaneous documentation by the Registered Nurse (RN) who administered the medication. Although a late entry was made nearly a month later by a Licensed Vocational Nurse (LVN) who witnessed the administration, facility policy required that the original staff member document medication administration at the time of service. Multiple staff interviews confirmed that if medication is not documented, it is considered not given, and the facility's policies emphasized the importance of timely and accurate documentation. Additionally, the resident's Baseline Care Plan inaccurately documented the resident's cognitive status as intact, despite multiple assessments and staff interviews indicating the resident had severely impaired cognition and was dependent on staff for activities of daily living. The inaccurate documentation in the care plan did not reflect the resident's true condition, as confirmed by the staff and the Minimum Data Set (MDS) assessment. These documentation failures were identified through interviews, record reviews, and policy reviews. The Director of Nursing (DON) and other staff acknowledged that documentation must be accurate and completed at the time care is rendered, and that inaccurate or missing documentation could lead to confusion in care and an inaccurate plan of care for the resident.