Failure to Maintain Complete and Accurate Medication, Treatment, and ADL Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, including medication administration, treatments, and activities of daily living (ADL) documentation, for multiple residents. Facility policies required that all medications administered, treatments performed, and services provided be documented in the clinical record. For one resident, physician orders for several medications, including mirtazapine, Seroquel, and ophthalmic solutions, were written to be administered on a specific evening, but the Medication Administration Record (MAR) contained no documentation that these medications were given. The DON confirmed that these medications should have been documented as administered and, in the absence of documentation, the facility could not verify administration. Another resident had physician orders for daily sacral pressure ulcer wound care, use of a low air loss mattress, and pain assessments prior to wound care, as well as a care plan indicating assistance was required for bed mobility, toileting, and transfers. The Treatment Administration Record (TAR) showed no documentation that wound care was provided on several dates, and there was no documentation that the low air loss mattress and pain assessments were provided on multiple dates. ADL documentation for this resident also lacked entries for bed mobility, toileting, and transfers on several days. A contracted wound care nurse stated that these treatments and pain assessments should have been documented as provided. For another resident who required total assistance with bed mobility, ADL records over a multi-day period lacked documentation of bed mobility assistance on numerous shifts; the CNA Supervisor and DON both acknowledged that this documentation was missing and should have been present. Additional residents were affected by similar documentation failures. One resident had multiple medications ordered, including atorvastatin, hydrocortisone suppositories, melatonin, trazodone, Xarelto, and buspirone, to be administered on specified evenings, but the MAR did not show that these medications were administered as ordered; the DON confirmed the lack of documentation. Another resident with orders for heel pressure ulcer wound care, a low air loss mattress, pain assessments prior to wound care, and staff assistance with ADLs had missing documentation on the TAR and ADL records for multiple dates, and both the CNA Supervisor and DON agreed that assistance and treatments should have been documented. A further resident had orders for gabapentin, latanoprost, melatonin, sertraline, and amoxicillin-clavulanate for administration on a specific evening, but the MAR lacked documentation of administration; the DON again confirmed that these medications should have been documented as given. Across all these cases, the facility was unable to verify that ordered medications, treatments, and ADL services were provided due to incomplete and inaccurate records.
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