Failure to Document PRN Medication Administration in Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one resident. According to the facility's policy, medications must be administered and documented in accordance with physician orders and professional standards. A review of the resident's medical record and Medication Administration Record (MAR) revealed that two tablets of acetaminophen 325 mg and one tablet of baclofen 5 mg, which were ordered to be given as needed, were not documented as administered on a specific date and time. The progress notes also lacked documentation of these medications being given. Interviews with the resident's family member and the LVN confirmed that the medications were administered between 1200-1300 hours, but the LVN acknowledged failing to document the administration in the MAR. The RN corroborated that the LVN had verified the administration verbally but was unable to document it. The Director of Nursing was informed of these findings and acknowledged the expectation that licensed nurses document medication administration immediately after giving medications.