Failure to Document PRN Medication Administration and Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for PRN medications, including documentation of administration and resident response, as required by physician orders and facility policy. For one resident with a history of opioid and cocaine dependence and a care plan identifying risk for substance use, the physician had ordered intramuscular and intranasal Naloxone (Narcan) as needed for suspected overdose. On the day of the event, the DNS responded to a STAT page and found the resident unresponsive on the bathroom floor with no pulse. CPR was initiated, 911 was called, and Narcan was administered twice without effect before the resident was transferred to the ED, where death was reported. A Narcan Administration Report documented the times and lack of effectiveness of both doses, but the MAR for that date did not contain any documentation that Narcan had been administered or its effectiveness, despite the DNS stating that administered medications should be signed off in the MAR. For another resident with chronic respiratory failure, sepsis, heart failure, bowel and bladder incontinence, and a history of addiction, physician orders included PRN Milk of Magnesia (MOM) for constipation and PRN Bisacodyl suppository if MOM was ineffective. The resident was also ordered PRN Ondansetron for nausea and vomiting. The MAR showed that Ondansetron was administered for nausea and vomiting and that Bisacodyl was administered later that night. An abdominal scan identified diffuse constipation. However, the MAR did not show that MOM had been administered, and it did not document the effectiveness of either MOM or Bisacodyl. The nursing supervisor on the night shift reported that the APRN ordered MOM in prune juice and a suppository, and that these were administered by an LPN. The LPN caring for the second resident stated she administered Ondansetron earlier in the evening with noted improvement, and later, after multiple episodes of vomiting, she believed the resident should be transferred to the hospital. She reported administering MOM around midnight but acknowledged that she did not document its administration or outcome. The DNS stated that the timing of follow-up assessment after MOM administration depends on the resident and could range from one hour to a few hours. Facility policy on administration procedures for all medications directed that when administering PRN medications, staff must document the reason for giving the medication, observe for actions or reactions, and record on a PRN effectiveness sheet or similar form. These requirements were not met in the cited instances for both residents.
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