Incomplete and Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain a complete and accurately documented clinical record for one resident, as evidenced by inaccurate and missing documentation on the Medication Administration Record (MAR). Specifically, an order for Aminocaproic Acid was not administered as prescribed due to the medication being unavailable, yet the MAR was inconsistently documented. On several occasions, nurses recorded the medication as unavailable in the morning, while other staff documented it as administered in the evening, despite confirmation from staff and the DON that the medication had not been delivered to the facility. Additionally, the MAR for the same resident was missing staff signatures for the administration of Linzess and lacked documentation of blood glucose results, insulin administration, and staff signatures for Novolin R on a specific date. Interviews with nursing staff and the DON confirmed that the medication was not present in the facility and that the documentation indicating it was given was a mistake. The DON stated that medications are expected to be delivered within 24 hours and that staff are required to notify her of any delays. She also confirmed that accurate documentation of medication administration is an expectation and that missing signatures are not acceptable. The findings were based on direct review of the resident's medical record and staff interviews.