Incomplete and Inaccurate Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically regarding the documentation of controlled substances and medication administration. For one resident with severe cognitive impairment and a diagnosis of megaloblastic anemia and generalized anxiety disorder, the Individual Narcotic Record for Lorazepam was not signed as given on multiple occasions by both the ADON and an LVN. Additionally, discrepancies were observed between the amount of medication remaining in the bottle and the amount documented on the narcotic record. Staff interviews confirmed that the process for administering and documenting narcotics was not consistently followed, with staff acknowledging that missing signatures could lead to confusion and miscommunication regarding medication administration. For another resident with multiple diagnoses including a right arm fracture, diabetes mellitus type 2, and cervical disc displacement, the Medication Administration Record (MAR) for Hydromorphone was not initialed as given by an LVN, even though the Individual Narcotic Record indicated the medication had been administered. Staff interviews revealed that the LVN evaluated the resident before and after medication administration and stated that documentation was completed on both the MAR and narcotic sheet, but the MAR was missing the required entry. The DON confirmed that audits and in-services on medication administration and documentation were ongoing, and that discrepancies in documentation could result in medication errors. Facility policy required that staff sign the MAR after administering medication and, for controlled substances, also sign the narcotic record. Policies also mandated that all assessments, observations, and services provided be documented in accordance with state law and facility policy, including recording the date, time, and credentials of the person making the entry. The observed failures to document medication administration and narcotic usage as required by policy resulted in incomplete and inaccurate medical records for the affected residents.