Failure to Document, Administer, and Notify Regarding Ordered Medication
Penalty
Summary
Facility staff failed to provide care in accordance with accepted standards of practice for a resident who had an order for boric acid vaginal suppositories. The staff did not accurately document the administration or non-administration of the medication, with inconsistencies noted in the Medication Administration Record (MAR) and a lack of corresponding progress notes. There were instances where the medication was marked as refused or held, but staff interviews revealed that these entries may have been inaccurate, as the medication was not available in the facility at the time. Additionally, staff did not consistently notify the physician of missed doses or refusals as required by facility policy. The medication was not available for administration for several days after the order was written, and there was confusion among staff regarding the procurement and location of the boric acid suppositories. Central supply did not have the medication in stock and had to order it from an outside supplier, resulting in a delay. During this period, staff documented refusals or held doses on the MAR, but did not make explanatory notes or notify the physician in a timely manner. Interviews with nursing and supply staff indicated a lack of clarity about the process for obtaining over-the-counter medications and the appropriate documentation and notification procedures when medications are unavailable or refused. The resident's care plan did not address the use of or refusals related to the boric acid suppository, despite multiple missed doses and documentation issues. Staff interviews revealed uncertainty about who was responsible for updating care plans in such situations. The facility's policies required accurate documentation, timely physician notification, and care planning for medication refusals, but these procedures were not followed in this case.