Failure to Document and Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident, who had multiple complex medical diagnoses including chronic kidney disease, heart failure, dementia, and other serious conditions. The resident was not cognitively intact, as indicated by a BIMS score of 6. Review of the medication administration record (MAR) for October showed that scheduled doses of Carvedilol and Sodium Zirconium Cyclosilicate (Lokelma) were not documented as given on two separate dates. The MAR had blank boxes for these medications, with no documentation indicating whether the medications were administered or the reason for omission. Interviews with nursing staff and the Director of Nursing (DON) confirmed that facility policy requires immediate documentation of medication administration or the reason for withholding a dose. Staff acknowledged that a blank box on the MAR means the medication was not given, and if a medication is held, the reason must be documented. The DON and staff could not provide a reason for the missing documentation or confirm whether the medications were actually administered. Progress notes for the relevant dates did not contain any entries explaining the omissions, and the assigned nurses either could not recall the events or admitted to possibly forgetting to document. Facility policies and job descriptions reviewed by surveyors further confirmed the requirement for accurate and timely documentation of medication administration and reasons for any missed doses. Despite these policies, there was no evidence in the resident's records to explain the missed or undocumented doses, and staff interviews did not clarify the circumstances. The deficiency was identified based on the lack of documentation and failure to follow established procedures for medication administration and record-keeping.