HospitalInspections.org

Based on staff interviews, medical record review, and facility medication administration policy and procedure, the facility failed to provide medical record documentation to include content describing treatment and medication administration and progress and response to medication and services on one (1) of thirteen (13) medical records reviewed; patient medical record #9.

Findings Include:

Interview with Accreditation Director (AD) on 10/02/2024 at 9:00 a.m. to 9:45 a.m. confirms no documentation of subsequent vital signs after triage or medication administration documented for patient record #9 on 08/26/2024. She further confirms a late entry for medication by registered nurse (RN) #6 on 09/10/2024 at 9:54 p.m.

Interview with registered RN #6 confirmed she administered medication on 08/26/2024 and did not document it at point of administration. She confirms she made a late nurse entry to record administration on 09/10/2024 after 9:54 p.m. She further confirmed patient #9 was on a continuous vital sign monitor and no vital sign documentation after 3:57 p.m. on 08/26/2024.

Interview on 10/03/2024 at 2:10 p.m. with the Quality Director (QD) confirmed no medication administration record for patient #9. She further confirmed no vital sign documentation after initial triage vital sign documentation on 08/26/2024 at 3:57 p.m.

Medical record review for patient record #9 revealed no vital sign documentation after 08/26/2024 at 3:57 p.m. and no medication administration record. Review further revealed a late entry for medication administration on 09/10/2024 at 9:54
p.m. with no dosage amount or time of administration.

Review of the facility policy titled "Nursing Service, Medication Administration Check (MAK) for medication administration and documentation" dated 02/11/2020 revealed the facility has a policy to chart the medication as given at point of administration using scanning and electronic medical record. Review revealed on page 3 of 7, " ... At end of shift, return to check Med Summary for any unverified orders. Activate Worklist for any uncharted medications. Utilize MAK for shift to shift report to review ... outstanding physicians orders and any needed medication follow up ...", and further revealed on pages 3-4 of 7, " ... b. Charting a medication as not administered in the MAK ...select the medication that is not to be administered, select not admin, the medication is now designated to be charted as non-administered, select chart to complete ...".

During an exit conference on 10/03/2024 at 4:15 p.m. survey findings were discussed with the Chief Executive Officer, Chief Nursing Officer, Vice-President of Operations, QD, AD, and Chief Financial Officer and no additional information was submitted.