Failure to Accurately Document Medication Administration and Catheter Care
Penalty
Summary
The deficiency involves failures to maintain accurate and complete medical records and documentation for two residents. For a resident with morbid obesity, diabetes with neuropathy, chronic kidney disease, and COPD, the care plan identified risks related to hypoglycemia/hyperglycemia and nutritional problems, with interventions including glucose monitoring, insulin administration, medication monitoring, and weight and diet management. The resident had a standing order for weekly Mounjaro injections for diabetes and obesity management. Review of the MAR showed that on one date the dose was marked as not given because it was being reordered, and on two later dates the MAR was left blank, with no indication the medication was administered. Further review of nursing notes for the same periods revealed no documentation that the PCP was notified when the resident did not receive the ordered Mounjaro doses. The quarterly MDS showed the resident was cognitively intact, and a physician progress note confirmed ongoing diagnoses of morbid obesity, diabetes, and COPD, and recommended continuation of Mounjaro. In interviews, the resident reported he was supposed to receive Mounjaro weekly, mainly for weight loss, and stated that at times he did not receive the medication, though he could not recall specific dates. The DON confirmed the MAR entries showing the missed or undocumented doses and acknowledged there was no nursing documentation of physician notification, stating she believed the medication may have been given but not documented. For a second resident with paraplegia, hypertension, and neuromuscular bladder dysfunction, the care plan and Kardex indicated the need for catheter care per policy, keeping the catheter bag below bladder level and covered, and providing catheter care per policy and after each bowel incontinence episode, though no frequency was specified. The quarterly MDS documented that this resident had intact cognition, an indwelling catheter, and was dependent on staff for toileting hygiene. Review of the TAR for two consecutive months and the task bar over a one‑month period showed no documentation that catheter care was completed, and the physician orders listed only an indwelling catheter to continuous drainage with no catheter care order. In interview, the resident was unsure how often catheter care was provided, and the DON verified there was no physician order specifying catheter care and no documentation of its completion, stating she believed it was done every shift but not documented. The facility’s catheter care policy described the purpose of preventing catheter-associated UTIs but did not address documentation or frequency of catheter care.
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