Document accurate information about the event, including assessment, monitoring, interventions, actions, communications, and resident response. Include relevant comments from the resident and family regarding the event (e.g., “My family brought my new glasses yesterday. I have been having balance issues since I started wearing my new glasses”).
Document the timeline of care and treatment during and after a significant adverse event including vital signs, neuro checks (for witnessed and unwitnessed reports of head injury), acute symptom management (e.g., complaints of shortness of breath or difficulty breathing after a fall), and pain management. Document the transition of care if the resident is transferred to the emergency room or an acute care facility, including hand-off report to the accepting nurse.
Ensure that documentation regarding the adverse event is factual, concise, and complete. Avoid assumptions, opinions or accusations about the care and treatment. Do not blame or criticize the resident, family, other care team members, the facility, or other healthcare organizations.
Clearly document communication with the primary care physician, the resident (as appropriate), and the family (as appropriate). Assign responsibility for post-event follow-up communication with the resident and family.
Case Example: (This case example does not represent an actual legal or medical case. The names and story example were created for illustration purposes only.)
A certified medication aide informs the Director of Nursing that she has just given a resident the wrong medications. The medication aide is very emotional and upset, but is able to confirm that she gave Mrs. Mary Jones, Ms. Thelma Peterson’s medications. Mary Jones is a frail resident that weighs less than 90 pounds. Mary received her medications this morning which included an anti-hypertensive, an oral hypoglycemic, and a diuretic. Thelma Peterson is on several medications which include an anti-hypertensive, an anti-coagulant, a hypoglycemic medication, and a pain medication.
Mary Jones is monitored closely over the next 60 minutes and shows progressive changes in her vital signs and cognition. She is transferred to the emergency room and admitted to ICU. Mary Jones is hospitalized for several days with noticeable decline in her physical condition.
What to Document: Documentation must be complete and accurate and reflect the care that was provided, but does not have to draw attention to the adverse event by labeling with such terms as medication error or wrong medications administered. At a minimum, documentation should include the name of the medication(s), dosage, route, physician notification, resident monitoring, and resident response.
A good practice is the “Mother Standard.” What would you expect staff members to document and communicate regarding a medication error that was given to your mother?