Failure to Accurately Document Medication Administration and Care Tasks
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards and its own policies. Specifically, staff did not consistently document the administration of medications and completion of ordered care tasks on the Medication Administration Record (MAR) for two residents. The facility's policies require that all medications administered be recorded with time and staff initials on the MAR, and that the electronic MAR (E-MAR) serves as a permanent, legal document within the electronic health record. For one resident with multiple diagnoses including severe cognitive impairment, repeated falls, malnutrition, and dementia, there were multiple instances where staff failed to record the administration of medications such as Levothyroxine, Donepezil, Atorvastatin, Latanoprost, Memantine, and topical creams, as well as the completion of care tasks like applying an overlay on the mattress and ensuring the use of pillow heel boots. These omissions occurred across several dates and shifts, with missing documentation for both day and night shifts. Another resident, with diagnoses including diabetes and hypothyroidism and intact cognition, also had missing documentation for medication administration (Levothyroxine, Novolin R), blood glucose monitoring, and other ordered care tasks over several days. Interviews with administrative and nursing staff confirmed that while medications and care tasks were performed as ordered, the required documentation was not completed on the MARs for the affected residents. Staff acknowledged that the records were not accurate and should have been properly documented according to facility policy.