Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered.
The facility's "Medication Policy and Procedure" notes "if a client refuses a medication, then it must be documented in the EMR."
Client #1 was admitted on to the facility on July 22, 2025, and discharged on July 26, 2025. Client #1 refused her medications on July 25, 2025, at 5pm and 10pm. There was no documentation of this refusal in the electronic medication record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Nurse Manager retrained nursing staff on the policy of proper documentation of medication refusals on 7/31 and 8/14. Staff was retrained to document the refusal of the medication.
The Nurse Manager will audit monthly to ensure medication refusals are documented appropriately.
The Director of Quality Assurance will audit monthly to ensure medications are appropriately documented. |