Failure to Document Medication Administration in Resident Medical Records
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records for three residents, resulting in the absence of records reflecting the administration of prescribed medications. For each of the three residents, medical records and medication administration records (MARs) did not show documentation that evening medications were administered as ordered by the physician. The residents involved had various diagnoses, including depression, dementia, schizophrenia, cirrhosis, heart failure, anxiety, type 2 diabetes, and schizoaffective disorder. Despite physician orders for multiple medications, there was no record in the MARs for the scheduled 7:00 P.M. medication pass on the specified date. Interviews with the residents and the Director of Nursing (DON) confirmed the lack of documentation. One resident recalled receiving medications, while another was unsure. The DON verified that the medication aide responsible for administering the medications was unable to document in the electronic record due to forgetting her badge and did not use a paper MAR as a backup. A medication administration audit corroborated the absence of documentation for the affected residents. Facility policy required complete, accurate, and timely documentation, which was not followed in these instances.