Failure to Document and Administer Medications per Professional Standards
Penalty
Summary
Surveyors identified that the facility failed to provide services meeting professional standards of quality for one resident. Specifically, there were multiple instances of missing documentation for the administration of several prescribed medications, including those for pain, diabetes, hypertension, atrial fibrillation, and depression, as well as missing documentation for vital signs and blood sugar checks. The resident in question had diagnoses of diabetes, congestive heart failure, and atrial fibrillation, and was prescribed high-risk medications such as anticoagulants, hypoglycemics, and psychotropics. The facility's policy required nurses to document all medication administration in the electronic medication administration record (eMAR), notify supervisors of omissions, and ensure all medications and treatments were signed off at the end of each shift. Review of the resident's eMAR for February revealed blank entries for several medications and required monitoring tasks on specific dates and times, with no corresponding nursing progress notes indicating whether the medications were administered, refused, or if a provider was notified. Interviews with facility leadership confirmed the resident was present in the facility during the times in question, but the reason for the missing documentation could not be determined, as the nurses responsible were no longer employed. The DON and nurse manager confirmed that blank boxes on the eMAR indicated medications were not given and that refusals or omissions should have been documented and reported according to policy.