Failure to Ensure Medication Administration and Documentation Meets Professional Standards
Penalty
Summary
A facility nurse failed to provide nursing services in accordance with professional standards for medication administration and documentation for 23 out of 24 sampled residents. The nurse did not complete required documentation for medication administration, treatments, and monitoring as ordered by physicians during a 12-hour night shift. Multiple residents' Medication Administration Records (MARs) and treatment records were left incomplete, with numerous required tasks such as pain monitoring, psychotropic side effect monitoring, oxygen saturation checks, and medication applications not documented as performed. In some cases, medications were documented as administered in the MAR, but residents reported not receiving them. Interviews with residents and staff revealed concerns about missed or late medications, with one resident specifically stating she did not receive her thyroid medication and had filed a grievance. Staff members reported frequent complaints about the nurse in question, including uncertainty about whether medications had been given. An internal investigation by facility staff confirmed that the nurse had not completed documentation for 21 residents during the shift, and the electronic medical record system highlighted these omissions. The nurse claimed to have completed all required work but intended to enter documentation as late entries due to a migraine, which was not reported to the oncoming nurse. Review of the MARs and facility investigation showed that essential care tasks and medication administrations were not documented for a wide range of residents, including those with complex medical needs such as hospice care, anticoagulation therapy, and enhanced barrier precautions. The lack of documentation made it unclear whether residents received their ordered medications and treatments, and in some cases, residents with cognitive impairment were unable to confirm whether care was provided. The facility's review referenced professional standards for nursing documentation, emphasizing the need for timely, accurate, and comprehensive records, which were not met in this instance.