Deficiencies in Timely Admission Paperwork and Medication Administration Documentation
Penalty
Summary
The facility failed to ensure timely completion of admission paperwork for one resident and accurate medication administration documentation for another. For the first resident, the admission agreement was not completed in a timely manner, as the paperwork was signed by the resident instead of the designated Power of Attorney (POA), despite the resident having moderate dementia and a POA in place. The facility's policy requires that the admission agreement be signed by the resident or their representative at the time of admission, and a copy placed in the resident's permanent file. The interim administrator confirmed that the admission paperwork was not completed as required. For the second resident, there were discrepancies in the documentation and administration of medications. An LPN administered several prescribed medications but failed to administer the Flonase nasal spray, Artificial Tears, and Lidocaine patch at the scheduled time. Despite this, the LPN documented on the Medication Administration Record (MAR) that the Flonase and Artificial Tears had been administered, and noted the Lidocaine patch as unavailable. The LPN later acknowledged that she typically completed treatments at a later time and had documented administration before actually giving the medications, which is contrary to facility policy. The facility's policies on medication administration and documentation require that medications be administered within one hour of the prescribed time and that documentation occur immediately after administration, not before. The policies also specify that all relevant details, including reasons for withheld or unavailable medications, must be accurately recorded. The failure to follow these procedures resulted in inaccurate records for the resident's medication administration.