Inaccurate Medication Administration Documentation by LVN
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN 3) inaccurately documented the administration of a prescribed pain medication, oxycodone-acetaminophen, to a resident. The resident, who was admitted with diagnoses including type two diabetes mellitus, a cervical vertebra fracture, and a scalp abrasion, was ordered to receive oxycodone-acetaminophen 7.5-325 mg three times daily for pain management. The Medication Administration Record (MAR) indicated that the medication was given at 6:00 a.m. on 6/14/2025. However, upon review, it was found that the resident did not receive the medication as documented. The resident reported not receiving any pain medication except Tylenol, which was ineffective for his pain, and stated he left the facility the morning after admission due to lack of pain management and other comfort issues. Further investigation by nursing staff confirmed that the bubble pack containing the prescribed oxycodone-acetaminophen remained intact with all 30 tablets present, and the controlled drug record also showed no doses had been dispensed. There were no doses available in the emergency medication kit either. During interviews, LVN 3 admitted to mistakenly documenting the administration of the medication when it had not been given, attributing the error to being rushed while tending to another resident. The Director of Nursing confirmed that the documentation was inaccurate and did not reflect the actual care provided. Facility policies require accurate and timely documentation of medication administration, and the failure to do so resulted in an inaccurate medical record for the resident.