Failure to Timely Document Medication Administration for Resident with Respiratory Conditions
Penalty
Summary
A deficiency occurred when licensed nursing staff failed to document medication administration for a resident with significant respiratory conditions, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and required multiple inhaled medications as part of their treatment plan. The Medication Administration Record (MAR) and audit reports revealed that documentation of medication administration was not completed at the time medications were given, but instead was entered days or even weeks later, often only after audits identified missing entries. The audit of the resident's MAR for December showed numerous instances where scheduled medications were administered at times different from those ordered, and documentation was delayed until prompted by the facility's Medical Records Assistant (MRA). Interviews with the involved LVNs confirmed that they could not recall specific details about medication administration for the resident, including which medications were given or the exact times of administration. The LVNs admitted to documenting medication administration retroactively after being notified of missing documentation during audits, rather than at the time of administration as required by facility policy. The facility's policy stated that staff must document medication administration immediately after giving each medication and before administering the next one. The DON confirmed that timely documentation is necessary for accurate monitoring of medication effectiveness and adverse reactions. However, the practice observed was that documentation was completed only after audits identified missing entries, and there was no contemporaneous record of medication administration or reasons for late documentation in the resident's progress notes.