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Shawn Wills, an eighty-year-old Sunnyville resident, recently came to your attention after an attorney representing his estate requested Mr. Wills’ medical records. Mr. Wills was a patient at your facility for over a year before passing away last month from heart failure. Mr. Wills was described by Sunnyville nursing staff as friendly and outgoing, and several staff members observed that he seemed to enjoy his time at the facility. Mr. Wills was diagnosed with congestive heart failure, for which his doctors prescribed daily medications. Sunnyville’s nursing staff was in charge of administering his daily medications and documenting the dose and time of administration in his medical record.

According to your review of Mr. Wills’ medical records, the nursing staff failed to record his medication administrations on the two days preceding his death. You also notice eight other occasions during his 13-month stay when there was no record of him receiving his daily medication. When you question the nursing staff about these omissions, they explain that they sometimes forget to report the administration of routine medications during particularly busy times in the facility.

What are the themes and laws, as well as the procedures that should be followed in this case?


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