Failure to Document Medication and Treatment Administration in Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, there were multiple instances where medications and treatments administered to the resident were not documented in the electronic health record system. The missing documentation included several dates where medications such as Levothyroxine and Midodrine, as well as catheter care and placement checks, were not signed off by the responsible nursing staff. This lack of documentation was identified through a review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), which showed unsigned entries for the administration of prescribed medications and completion of required treatments. The resident involved had complex medical needs, including hypothyroidism, hemiplegia, insomnia, diabetes insipidus, and muscle weakness. Physician orders were in place for thyroid replacement therapy, blood pressure medication, and catheter care, all of which required consistent administration and monitoring. Despite these orders, the MAR and TAR revealed that on several occasions, the required medications and treatments were not documented as given. Written statements from the involved nursing staff indicated that the medications and treatments were administered, but the staff forgot to document these actions in the records at the time of administration. Interviews with facility leadership confirmed that it was the expectation for nursing staff to document all administered medications and treatments in the MAR/TAR immediately after completion. The absence of documentation meant that it could not be confirmed whether the care was provided, as the records would indicate the tasks were not completed. The facility's policy also required that each medication order be documented with the date, time, and signature of the person administering the medication, which was not followed in these instances.