Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to ensure accurate clinical documentation for a resident, identified as Resident 108, regarding the administration of a Prenatal Oral Tablet. Physician orders indicated that Resident 108 was to receive a prenatal vitamin with ferrous fumarate-folic acid daily. However, the Medication Administration Record (MAR) for January 2025 showed discrepancies. Staff documented the administration of the medication on several days, while other notes indicated the medication was unavailable due to it not being in house stock. Despite this, the medication was recorded as administered on multiple occasions. The issue was brought to the attention of the Nursing Home Administrator and Director of Nursing, and it was revealed that the medication order was not updated in the electronic health record. A licensed practical nurse, identified as Employee 13, confirmed that the inconsistency was due to a documentation issue. The Prenatal Oral Tablet was eventually discontinued, and a new order for a Multivitamin-Minerals Oral Tablet was placed after the surveyor's review.
Plan Of Correction
The order for resident 108 was discontinued and replaced with an appropriate order. A house audit of current resident's medications will be completed to ensure that all medication is available. Nursing staff will be re-educated on the importance of accurate documentation. The DON or designee will complete weekly audits of 5 residents x 8 weeks to ensure that resident medications are available and the medical record has accurate documentation of the medication administration. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.