F0658

F

Failure to Document Critical Clinical Events and Administer Medications as Ordered

Kansas City, Missouri Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves failures by licensed nursing staff and the social services designee (SSD) to document critical changes in a resident’s condition and treatment, as well as failures by nursing staff to administer and/or document medications as ordered for multiple residents. One resident with intact cognition, end-stage renal disease on hemodialysis three times weekly, insulin-dependent diabetes, chronic infected wounds with osteomyelitis, prior lower extremity amputation, atrial fibrillation, and congestive heart failure had a critical potassium level reported from an outpatient clinic. The clinic physician ordered that the resident be sent to the emergency room for treatment. RN A was notified of the critical lab and the order to send the resident to the hospital, spoke with the resident who refused transfer, and then contacted the facility nurse practitioner, who ordered an immediate 80 mEq dose of oral potassium and a STAT repeat potassium level. None of these events, including the resident’s refusal of hospital transfer, the new treatment plan, the STAT lab order, or the subsequent STAT lab results and provider notification, were documented in the resident’s clinical record.

For this same resident, the SSD completed a change in code status to Do Not Resuscitate (DNR) but did not document this interaction or other extensive contacts with the resident in the clinical record, instead keeping notes in a separate notebook. The SSD recalled the resident expressing a wish to change to DNR status after discussions with dialysis nurses, and a new DNR was completed, but there was no corresponding documentation in the facility chart. Additionally, there was no documentation that the dialysis clinic or physician were notified when the resident refused a scheduled hemodialysis treatment, which also included IV antibiotic therapy, nor was the missed dialysis/antibiotic treatment documented as such. Nursing progress notes around the time of the critical potassium result and subsequent events contained only limited entries (e.g., repositioning, offering water, and the time the resident was found without respirations and pulse), with no record of the critical lab, treatment decisions, refusals, or communication with outside providers.

The deficiency also includes failures to administer and/or document medications as ordered for three other residents. For one resident with multiple cardiac and nutritional medications, the MAR showed that on a specific date all ordered medications and supplements were marked with a code "9" (indicating to see progress notes), but the progress notes contained no explanation for why the medications were not administered. For another resident with numerous psychotropic, cardiac, pain, GI, and nutritional orders, the MAR likewise showed all medications and supplements coded "9" on a specific date, with no corresponding documentation in the progress notes explaining the omissions; in addition, gabapentin, buspirone, and Med Pass were not documented as administered at scheduled times. A third resident had ordered diltiazem three times daily and a nutritional supplement four times daily; on a specific date, both were coded "9" on the MAR, and a progress note explicitly stated that neither the medication nor the supplement had been administered.

Staff interviews further clarified the circumstances leading to the missed medications. The staffing coordinator reported that on the day in question a Certified Medication Technician (CMT) called in for the 100 halls, and despite attempts to find in-house or agency coverage, no replacement was obtained until 2:00 p.m. RN B, who had never previously passed medications in LTC, was instructed to begin passing medications while coverage was sought. RN B reported difficulty with medication administration, including not knowing which medications required crushing or mixing with food, and being simultaneously responsible for a resident with a medical emergency, wound care, and monitoring residents for falls or altercations. RN B acknowledged that some medications were passed but not all, and that when the CMT arrived at 2:00 p.m., the CMT declined to administer the overdue medications and told RN B to document them as not administered. RN B stated that if medications were not passed, he or she should have documented in the progress notes why they were not administered, but this was not done.