Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards and practices. Specifically, there were multiple instances where medication administration and treatments were not documented in the electronic medical record (PCC) for a resident with significant medical needs, including diabetes, muscle weakness, hypertension, and congestive heart failure. The resident's care plan included interventions for diabetes management, pain control, and suprapubic catheter care, all of which required consistent documentation to ensure continuity of care. Record reviews revealed that several medications and treatments, such as insulin administration, lidocaine patch application, air mattress checks, barrier cream application, and suprapubic catheter care, were not signed off as completed on the Medication Administration Record (MAR) on specific dates. Interviews with the involved staff confirmed that these medications and treatments were administered, but the staff failed to document them at the time of administration. The staff cited being occupied with other duties as the reason for the lack of timely documentation. The facility's policy on documentation and charting emphasizes the importance of maintaining a complete account of resident care, including medications and treatments, to guide physicians, measure quality of care, and serve as a legal record. Both the Director of Nursing (DON) and the Administrator acknowledged that failure to sign off on the MAR indicates that the medication or treatment may not have been given, which could have implications for the resident's care. The resident interviewed did not report any missed medications or treatments and expressed satisfaction with the care received.