Failure to Document Medication Administration as Ordered
Penalty
Summary
Facility staff failed to document the administration of medications as directed by physicians for three sampled residents. According to the facility's medication administration guidelines, staff are required to promptly record medication administration, including the date, time, dosage, and signature, immediately after giving the medication. For one resident with severe cognitive impairment, a feeding tube, and multiple diagnoses including stroke and epilepsy, staff did not document the administration of skin prep, tube feeding formula, several anti-seizure and psychiatric medications, or the required feeding tube flushes on multiple occasions as ordered by the physician. Another resident, assessed as cognitively intact with diabetes, had undocumented administration of prescribed insulin on two separate occasions. This resident reported that insulin was only given upon request and that staff sometimes claimed it was documented even when it was not received. A third resident, also cognitively intact and diagnosed with diabetes, chronic pain, and pneumonia, had no documentation of receiving prescribed pain medication, bronchodilator, and diabetes medication on a specified date. These failures were identified through interviews and record reviews, indicating noncompliance with established medication administration and documentation protocols.