Failure to Accurately Document Medication Administration and Error
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia with anxiety, depression, and PTSD, was administered lorazepam 0.5 mg earlier than prescribed. The registered nurse (RN) responsible for the medication pass did not verify the timing of the last dose before administering the medication, as required by the physician's orders. The RN realized the error after administration and notified the physician, who instructed monitoring for any reactions. However, the RN failed to document the call to the physician and did not complete an incident report regarding the medication error. Further review revealed that the administration of lorazepam was not documented on the resident's Medication Administration Record (MAR) as required by facility policy, although it was recorded on the Controlled Substance Accountability Sheet (CSAS). The facility's policies and procedures specify that all medications administered must be documented immediately on the MAR, including the date, time, dosage, and the nurse's signature or initials. The lack of documentation on the MAR meant that the medication administration was not accurately reflected in the resident's clinical record. Additionally, the incident was not fully documented in the resident's progress notes or clinical record. The progress note only briefly mentioned the medication error and ongoing monitoring, without providing a complete account of the error, notifications made, or subsequent physician orders. The facility's policy requires that medication errors be documented in both an incident report and the resident's clinical record, including all relevant details and notifications. The failure to follow these documentation standards resulted in incomplete and inaccurate medical records for the resident.