Failure to Complete Medication Administration and Post-Fall Assessments
Penalty
Summary
The facility failed to provide necessary care and services for two residents, resulting in deficiencies related to medication administration and post-fall assessments. For one resident with diagnoses including heart disease, COPD, sepsis, depression, dementia, and anxiety, the Medication Administration Records showed that prescribed medications (aspirin, Zoloft, and Norco) were not documented as administered on multiple occasions. Physician orders required these medications to be given via PEG-tube, but the records for October and November indicated several blank entries where medications were not signed out as completed. The Director of Nursing was unable to provide an explanation for the missed doses. Another resident, with diagnoses such as respiratory failure, COPD, diabetes, kidney disease, dialysis, and dementia, experienced an unwitnessed fall. Although initial neurological checks were started, the Neurological Assessment Form was not completed at several required intervals, and the 72-hour post-fall documentation was discontinued prematurely. The resident's care plan called for ongoing assessment and interventions following the fall, but documentation and follow-up assessments were not completed as required by facility policy. The Director of Nursing confirmed that the required neurological and post-fall assessments were not fully carried out.