Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include medication records, in one of seven records reviewed.Client # 5 was admitted December 4, 2024, and discharged December 9, 2024. The medication record indicated the client did not receive some of the medications as prescribed on 12/8/24 and 12/9/24. The record did not contain documentation of the reason why the medications were not given.
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Plan of Correction
Identification of Failure: Medications were not given and staff failed to document the reason the medication was not given.
Action: Staff were re-educated by the Nurse Manager on the requirement to document the reason that a medication was not given. All Nursing staff were required to sign an attestation form indicating they were retrained on the proper documentation of medication refusals.
Monitoring: Monitoring will be completed monthly by the Nurse Manager/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with documenting the reason that an ordered medication was not given. 25 charts will be audited each month with a goal of 100% compliance for 3 months.
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