Failure to Document and Verify Medication Administration
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services that meet the needs of each resident, specifically in the accurate administration and documentation of medications. For one resident with multiple diagnoses, including hypothyroidism, the Medication Administration Record (MAR) showed two blank entries for scheduled doses of levothyroxine, a thyroid medication. Facility policy requires that medications be administered as ordered and that the MAR be initialed after each administration. However, on two separate dates, there was no documentation to confirm whether the medication was given. Interviews with facility staff, including the Director of Nursing, Infection Preventionist, and several LPNs, revealed uncertainty and inconsistency regarding the meaning of blank boxes on the MAR. Staff responses indicated that a blank could mean the medication was not given, not documented, or simply not checked off, and there was no way to verify administration in these instances. The lack of documentation and clarity among staff led to the inability to confirm that the resident received their prescribed medication as ordered.