Nurse Documented Medication Administration Prior to Giving Medication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to follow facility policy by documenting the administration of hydrocodone-acetaminophen on both the Medication Administration Record (MAR) and the Controlled Drug Record before actually giving the medication to a resident. The nurse was observed preparing the medication, signing both records, and then administering the medication several minutes later. During an interview, the LVN confirmed that it was her practice to sign the records prior to administration to ensure the times matched on both documents. The resident involved had a history of rheumatoid arthritis, an artificial hip joint, and a history of falls, and was receiving pain medication as needed. Facility policy and the Director of Nursing (DON) both specified that documentation on the MAR should only occur after the medication has been administered, as residents may still refuse the medication. The facility's policy required immediate documentation following administration, but this was not followed in this instance.