Failure to Accurately Document Medication Administration and Blood Pressure Readings
Penalty
Summary
Licensed nursing staff failed to ensure accurate and reliable documentation of medication administration for a resident with multiple complex medical conditions, including end stage renal disease, muscle weakness, and hypertension. The resident had physician orders for midodrine to be administered only if systolic blood pressure (SBP) was 110 or below, as well as orders for methocarbamol and Norco. However, the Medication Administration Record (MAR) showed that midodrine was documented as given on several occasions when the resident's SBP was above the ordered threshold. Interviews with nursing staff revealed that doses were sometimes held but mistakenly documented as administered, and in one instance, a nurse incorrectly recorded the resident's SBP. Additionally, there was a failure to document the reason for holding methocarbamol. One nurse held the medication due to concurrent administration of Norco, believing it was unsafe to give both at the same time, but did not record this rationale in the MAR or nursing notes. This omission meant that subsequent staff were not informed of the reason for the held dose. The facility's policies required that all services, medication administration, and changes in resident condition be accurately documented to ensure communication among the care team. The Director of Nursing confirmed that all MAR entries, blood pressure readings, and nursing notes should accurately reflect the care provided. The lack of accurate documentation and communication regarding medication administration and resident condition was acknowledged by staff and leadership as not meeting facility policy and professional standards.