Incomplete and Inaccurate Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in documentation deficiencies on the Medication Administration Records (MARs) and nurse's notes. For one resident with diagnoses of atrial flutter and hypertension, the MARs for September did not include required documentation of heart rate and blood pressure when medications were held, leaving blank spaces where this information should have been recorded. The staff member responsible for administering the medication acknowledged that she held the medication but failed to document the action or the vital signs, and both she and another medication aide confirmed that there should be no blanks on the MARs. For another resident with hypertension, the MARs indicated that blood pressure medication was administered on two occasions when the resident's systolic blood pressure was below the physician-ordered threshold for holding the medication. There was no documentation in the nurse's progress notes explaining why the medication was given despite the low blood pressure, and the staff member later stated that the documentation was an error and that the medication was likely held but not properly recorded. The resident confirmed that her blood pressure medication was sometimes withheld due to low readings, and the staff member admitted to forgetting to document the reasons for holding or administering the medication. Interviews with staff, including the Assistant Director of Nursing, confirmed that the facility's expectation is for all medication administration and related vital signs to be documented accurately and without blanks, in accordance with facility policy. The lack of documentation made it difficult to determine whether medications were given or held as ordered, and whether physician instructions were followed.