Failure to Document Medication Administration and Monitoring in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for three sampled residents. Licensed Vocational Nurses (LVN) did not document the administration of medications on the Medication Administration Record (MAR) for the 3 PM to 11 PM shift on a specific date. This lack of documentation included both the administration of prescribed medications and required monitoring, such as behavior and side effect assessments, for residents with complex medical and psychiatric conditions. Resident 2 had multiple diagnoses, including seizures, dementia, COPD, and bipolar disorder, and required various medications and behavioral monitoring. The MAR for this resident was left blank for several medications and monitoring parameters during the identified shift. Similarly, Resident 3, who had severe cognitive impairment and required substantial assistance with daily activities, also had blank MAR entries for multiple medications and required monitoring. Resident 4, with diagnoses including COPD, hypertensive heart disease, and schizophrenia, had missing documentation for both medication administration and vital sign monitoring during the same shift. Interviews with facility staff confirmed that the standard practice is to document medication administration and monitoring immediately after providing care. Both the Administrator and Assistant Director of Nursing acknowledged that the assigned LVNs did not follow facility policy, resulting in incomplete medical records for the affected residents. Facility policies reviewed by surveyors emphasized the importance of timely and accurate documentation of all services provided, including medication administration and monitoring, to ensure proper communication and continuity of care.