Observations
Based on a review of client charts during a complaint investigation on August 2, 2022, the facility failed to follow their Medication Management policy MM-004.The Medication Management policy states that nursing staff will document the reason a medication was not administered to a client as prescribed. The facility staff did not document this information in three out of the four client charts reviewed.Client 1 was admitted 4/1/22 and discharged 6/14/22. The MARs showed that the client missed AM medication on April 20, 23, 25, 29, May 3, 8, 9, 14, 21, 28, 31, June 3, 4, 5, and 9. He also missed the PM medication April 11, 28, May 8, 12, 15, and June 7. No reason was documented for the client missing his medication. Client 2 was admitted on 6/10/22 and is a current client. The MARs showed that the client missed PM medication on July 5th at 5pm. No reason was documented for the client missing his medication. Client 3 was admitted on 5/4/22 and discharged on 6/10/22. The MARs showed that the client missed AM medication on May 7 and 26. No reason was documented for the client missing his medication.
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Plan of Correction
MLRC will ensure that all medications that are missed or refused are documented in the client's MAR. Director of Nursing will provide an education to Nursing Staff on proper documentation of refused and/or not taken medications. Director of Nursing will review the Medication Management policy with Nursing Department to ensure standards are being followed. Director of Nursing will audit MAR's weekly to ensure proper documentation is occurring. |