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Based on interview and documentation review of one of one applicable medical record, the nursing staff failed to: 1). consistently document that the Patient's daily hygiene needs were met and 2). document on the Medication Administration Records that on 1/7/10 an IV medication was administered.

Findings included:

Review of nursing documentation from 12/24/09-1/29/10 indicated that AM care was provided to the Patient on all days except 12/30/09, 1/15/10, 1/17/10, 1/25/10 and 1/26/10.

Documentation in the Patient's medical record, dated 1/5/10 indicated that the Patient's physician ordered Ertapenem 1 gram (Gm) intravenous (IV) daily and the first dose to be now.

Review of the Patient's Medication Administration records, dated 1/5/10, 1/6/10 indicated Ertapenem was administered as ordered.

Review of Physician Orders, dated 1/7/10 indicated to continue Ertapenem through 1/12/09. However, review of the Patient's medication administration records indicated that on 1/7/10 the nursing staff failed to document the antibiotic was administered as ordered.

Interview with the Director of Nursing indicated the nurse assigned to the Patient on 1/7/10 stated to her that she administered the antibiotic, however, she failed to document it on the medication administration record.

Based on documentation review, it was determined that the nursing staff failed to administer a medication to the Patient in accordance with the Physician's orders.

Findings included:

The Physician's orders indicated that on 1/5/10 at 5:00 PM an order was written for Ertapenem 1 gram (Gm) intravenous (IV) daily with the first dose to be now.

Review of the Patient's Medication Administration records, dated 1/5/10, 1/6/10 indicated Ertapenem was administered as ordered.

Review of Physician Orders, dated 1/7/10 indicated to continue Ertapenem through 1/12/10.

Review of medication administration records indicated the antibiotic was not administered as ordered on 1/7/10.