Failure to Document Reasons for Missed Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation regarding the administration of medication for one resident diagnosed with left eye keratitis. The resident's Medication Administration Record (MAR) showed that several doses of a prescribed ophthalmic solution were not administered on specific dates and times. However, there was no corresponding nursing documentation explaining the reason for the missed doses. The resident's medical record lacked any notes indicating why the medication was withheld, whether the physician was notified, or what follow-up actions were taken regarding the missed medication. Interviews with the Director of Nursing (DON) and the facility Administrator confirmed that the absence of documentation did not meet the facility's expectations or policy requirements. The facility's policy on medication administration documentation requires that reasons for withholding or not administering medication be recorded, along with any related follow-up. The deficiency was identified through record review and staff interviews, which verified that the required documentation was missing for the resident in question.