Inaccurate Medication Administration Documentation Due to Improper Charting and Resident Refusal
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to accurately document medication administration for a resident with amyotrophic lateral sclerosis (ALS), major depressive disorder, and type 2 diabetes. The resident, who was cognitively intact and able to make decisions, refused to accept medications from one LVN due to concerns about dignity and respect. The LVN prepared the medications and pre-charted their administration in the Medication Administration Record (MAR) before actually giving them to the resident. When the resident refused to take the medications from the first LVN, the medications were handed to a second LVN. The resident also refused to take the medications prepared by the first LVN, leading the second LVN to waste those medications and prepare a new set in the resident's presence, which the resident then accepted. Despite this, the MAR reflected the first LVN's initials for the administration, and the second LVN did not update the record to accurately show who administered the medications. Interviews with both LVNs confirmed that the first LVN pre-charted the medications and did not document the resident's refusal as required by facility policy. The second LVN acknowledged not correcting the MAR to reflect the actual administration. The facility's policy and job descriptions require accurate, timely documentation by the nurse who administers medications, including proper notation of refusals and the identity of the administering nurse. This failure resulted in inaccurate documentation of medication administration for the resident.