Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, specifically regarding the documentation of medication administration. For one resident with diagnoses including COPD, CKD, schizophrenia, and diabetes, there were multiple instances where oxycodone-acetaminophen was signed out for administration, but the corresponding medication administration record (MAR) either lacked documentation of administration or had discrepancies in timing. On several occasions, the medication was signed out at specific times, but there was no documentation to confirm that the medication was actually administered. Similarly, for another resident with diagnoses including above-the-knee amputation, COPD, and peripheral vascular disease, the MAR and sign-out sheets for oxycodone showed that the medication was signed out at various times, but documentation of administration was either missing or did not correspond with the sign-out times. Interviews with the DON and Administrator confirmed that the facility was unaware of these documentation lapses until the issue was identified during the survey. Facility policy requires that the date and time of medication administration be recorded in the resident's medical record, which was not consistently followed in these cases.