Failure to Document Acute Symptoms and PRN Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident experiencing acute medical symptoms and receiving PRN medication. A nurse reported that, a couple of days prior to 2/3/26, the resident vomited undigested food. She assisted with cleaning the resident and provided ginger ale and soup for supper, and recalled no further complaints or vomiting after that single episode. However, review of the resident’s record showed no documentation of this vomiting episode or the care provided at that time. On a separate shift, another nurse reported that during the night shift spanning 2/2/26 to 2/3/26, the resident complained of gas and stomach pain. The nurse stated she administered Milk of Magnesia under a standing PRN order but did not recall the exact time. Record review revealed no documentation of the administration of this PRN medication. The Medical Director stated that staff should document clinical symptoms and any treatment rendered, as this information is used when providers review acute illnesses. The DON confirmed that the vomiting episode and the PRN medication administration were not documented, leaving the resident’s medical record incomplete.
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