Failure to Document Medication Orders and Administration in Resident Record
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical record was complete regarding medication orders and documentation of medication administration. A resident with metastatic lung cancer was admitted and, during an episode of non-responsiveness, a Nurse Practitioner (NP) gave verbal orders for two doses of Narcan and one dose of Lasix. These medications were administered by nursing staff, as confirmed by sign-out records from the emergency medication supply. However, the orders were never entered into the resident's electronic medical record, and the administration of these medications was not documented on the Medication Administration Record (MAR). Multiple nurses were present when the NP gave the orders, but the NP did not specify which nurse was responsible for entering the orders. One nurse attempted to enter the order for Narcan but was unable to find the correct form in the electronic system, resulting in the order not being entered and the administration not being documented. Interviews with staff confirmed that the medications were administered per the NP's verbal orders, but no documentation was made in the resident's record or MAR, as required by facility policy and professional standards.