Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician and that medication administration was properly documented for a resident with multiple diagnoses, including dementia, hypertension, and depression. Review of the Medication Administration Record (MAR) revealed that several prescribed medications, such as ascorbic acid, famotidine, ferrous sulfate, folic acid, lisinopril, multiple vitamins, zinc sulfate, docusate sodium, and prostat oral liquid, were not signed as given on multiple occasions. The MAR lacked documentation indicating whether these medications were administered or, if not, the reasons for omission. The facility's policy requires that the licensed nurse chart the drug, time administered, and initial their name with each medication administration, which was not followed in these instances. During an interview, the DON confirmed that the MAR should be signed immediately after medication administration and agreed that unsigned entries indicate the medications were not given. The resident involved was noted to have moderately impaired cognitive function and required significant assistance with daily activities, making accurate medication administration and documentation particularly important. The failure to document medication administration as required resulted in the facility being unable to determine if the medications were given, as well as failing to prevent potential medication errors, duplication, or delays in care.