Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of five residents reviewed. For one resident, the Medication Administration Record (MAR) for October did not reflect documentation that Diclofenac Sodium External Gel 1% was administered as ordered three times a day. Specifically, there was a blank entry for the 5:00 pm administration on one date, and no documentation in the nurse's progress notes explaining why the treatment was not provided or documented. For another resident, the Treatment Administration Record (TAR) for October did not show documentation that an Accu-Chek blood glucose check was performed as ordered in the evening. The TAR contained blank entries for the required Accu-Chek, and there was no corresponding nurse's note to explain the omission. Both residents had complex medical histories, including conditions such as anemia, heart failure, diabetes, and cognitive impairment, and were dependent on staff for various aspects of care. Interviews with nursing staff confirmed that there should be no blanks on the MARs or TARs, and that all treatments and medications administered or not administered must be documented, including reasons for any omissions. The facility's policy also requires that all services, medications, and treatments be objectively, completely, and accurately documented in the resident's medical record by licensed personnel.