Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for five residents. For one resident with multiple food and drug allergies, staff did not transcribe a physician's order for Benadryl, failed to document an assessment of an allergic reaction after the resident was served fish, and did not update the care plan to address allergies. Interviews and record reviews confirmed that the allergic reaction was not properly documented, and there was no evidence of the medication being administered or the event being recorded in the clinical record. Another resident received medications outside of the scheduled administration window on multiple occasions, as shown by medication administration records. The medications involved included midodrine, sennosides-docusate sodium, carbamazepine, and pregabalin. Nursing staff confirmed that medications should be administered within a two-hour window for resident safety, but records showed doses given significantly outside this timeframe. Additionally, for three separate residents involved in resident-to-resident altercations, staff failed to document the incidents in the clinical records as required by professional nursing standards. Facility synopses described the altercations and subsequent assessments, but there were no corresponding progress notes in the residents' clinical records. Interviews with nursing staff and administration confirmed that documentation of such events is a basic nursing practice and should include a description of the incident, steps taken to ensure safety, and assessment results.