Inaccurate Medication Administration Documentation by Nursing Staff
Penalty
Summary
A deficiency occurred when a licensed nurse (LN B) initialed the medication administration record (MAR) for a medication that was actually prepared and administered to a resident by another licensed nurse (LN A). According to the facility's policy and procedure for administering medications, the individual who administers the medication is required to initial the MAR on the appropriate line after giving each medication and before administering the next dose. However, LN B confirmed during an interview and record review that she checked off the administration of oxycodone for the resident, despite not being the one who gave the medication. The resident involved had a medical history that included an unstageable pressure ulcer of the sacral region, depression, and dementia, and was not their own responsible party. The Director of Nurses (DON) confirmed that nurses should not sign out medication they did not administer. This failure to follow established medication administration documentation procedures resulted in inaccurate records for the resident.