Failure to Accurately Document Medication Administration and Bathing Records
Penalty
Summary
The facility failed to ensure accurate and complete documentation of medication administration and bathing records for two residents. For one resident with multiple diagnoses including diabetes, morbid obesity, and a surgical wound infection, there were several instances where the administration of IV cefepime was not signed off in the medication administration record on specific dates and times. Nursing progress notes did not address these missing entries, and the DON confirmed the omissions, attributing them in part to the lack of an IV-certified nurse on the unit and reliance on supervisors to administer the IV medication, who may have failed to document administration. For another resident with dementia, depression, and a history of strokes, bathing records over several months were found to be incomplete, with multiple shifts lacking documentation on whether a shower or bath was offered or provided. The DON verified that the bathing records were incomplete. These findings were identified during a complaint investigation and represent failures in maintaining accurate and complete medical records in accordance with professional standards.