Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain an accurate record of medication administration for one resident. The resident, who had no cognitive impairment and diagnoses including acute respiratory failure with hypoxia and chronic lung disease, had a physician's order for an Albuterol inhaler to be administered as needed for wheezing. Review of the Medication Administration Record (MAR) for April showed a lack of documentation that the resident received the inhaler from April 1st to April 13th, despite the order being in place. Staff interviews revealed that on at least one occasion, the resident requested the inhaler, but it could not be located by the staff at that time. The inhaler was eventually found, but it was a different color than the one the resident had previously used, though it was the same medication and dose. Staff involved did not document the administration of the inhaler on the MAR for the night it was given or for a night or two prior, as required by facility policy. The policy stated that the individual administering the medication must record the administration on the MAR immediately after giving the dose. The lack of documentation and the confusion regarding the location and identity of the inhaler led to the deficiency cited by surveyors.