Failure to Document IV Therapy and Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for three residents who received intravenous (IV) therapy. For one resident with multiple diagnoses including pneumonia, respiratory failure, and dehydration, there was a physician order for peripheral IV insertion, but no documentation was found in the nursing progress notes regarding the insertion, site, or care of the IV. The DON confirmed that documentation should have included details such as the location of the IV, number of attempts, success of the procedure, fluids administered, and site condition, but these were missing. Nursing staff interviews revealed confusion about the presence of orders and a lack of documentation regarding IV care and communication with the resident's representative. Another resident, admitted with acute osteomyelitis, diabetes, and a history of stroke, had documentation indicating a peripheral IV was present and a physician order for its removal. However, there were no nursing progress notes documenting the removal of the IV during the relevant period. This lack of documentation failed to meet the facility's own policy requirements for recording vascular access procedures and care. A third resident, admitted with complex medical conditions including osteomyelitis, spina bifida, and paraplegia, had physician orders for IV antibiotics. The Medication Administration Record (MAR) showed multiple missed doses of vancomycin and cefepime, with chart codes indicating to see nurses' notes, but the corresponding nursing notes were absent. Interviews with LPNs revealed that medication orders were not entered promptly, medications were not available, and provider notifications were either not made or not documented. Staff acknowledged that they should have documented provider notifications and actions taken regarding missed medications, but this was not done.