Question - The case of Shawn Wills, an eighty-year-old resident at Sunnyville, recently came to your attention when an attorney representing his estate requested Mr. Wills' medical records. Mr. Wills resided in your facility for over a year before he passed away from heart failure last month. Sunnyville nursing staff described Mr. Wills as friendly and outgoing, and several staff members observed that he seemed to enjoy his time at the facility. Mr. Wills had congestive heart failure for which his doctors prescribed daily medications. The nursing staff at Sunnyville was in charge of administering his daily medications and recording the dose and time of administration in the patient's medical record.
In your review of Mr. Wills' medical records, you see that the nursing staff did not record his medication administrations on the two days prior to his death. You also notice eight other instances during his 13 months stay when there was no record that he received his daily medication. When you ask the nursing staff about these omissions, they tell you that they occasionally forget to report the administration of routine medications during particularly busy times in the facility.
What is the themes and laws with procedures that should be taken in this case?