Inaccurate Medication Documentation Due to Undispensed Medication
Penalty
Summary
Licensed nurses failed to follow professional standards of practice by documenting the administration of Budesonide, a respiratory medication, to a resident with COPD and asthma, despite the medication never being dispensed by the pharmacy. Observations showed that the medication was not present in the medication cart, and multiple nurses confirmed through interviews and record reviews that they had documented giving the medication on several occasions in April and May, even though it was not available. The pharmacy had requested clarification regarding the resident's respiratory medications due to concerns about duplicate therapy, but the facility did not respond, resulting in the medication not being delivered. Further review of the resident's Medication Administration Record (MAR) revealed repeated entries indicating the administration of Budesonide, which was confirmed by the Director of Nursing to be inaccurate since the medication was never dispensed. Facility policies and professional guidelines reviewed during the investigation emphasized the need for accurate, truthful, and comprehensive documentation, as well as verification of medication availability prior to administration. The failure to adhere to these standards resulted in inaccurate documentation for the resident.