Falsification of Medication Administration Records for Ophthalmic Medications
Penalty
Summary
Licensed staff failed to accurately document medication administration for a resident with multiple diagnoses, including glaucoma, hypertension, and pain syndrome. The resident had physician orders for several ophthalmic solutions and artificial tears to be administered at specific times daily. During medication administration observation, the nurse prepared and administered oral medications but did not include any of the prescribed eye drops. Despite this, the Medication Administration Record (MAR) reflected that the eye drops were administered at the scheduled times. Further review revealed that the resident was assessed as unable to self-administer medications, with a physician order specifying that all medications were to be given by a licensed nurse. The nurse initially claimed to have administered the eye drops, then stated the resident self-administered them, and finally acknowledged that the medications were not administered and that documentation indicating otherwise was incorrect. The nurse also admitted that some of the prescribed eye drops were not available in the medication cart and would need to be reordered from the pharmacy. The Director of Nursing confirmed that the facility had not reassessed the resident for self-administration and that nurses were not permitted to document medications as given when they were not administered. Facility policy required that only the individual who administers the medication should document it on the MAR immediately after administration, and that unadministered doses should be documented as such. The failure to follow these procedures resulted in inaccurate medical records for the resident.