Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate documentation for one resident. Review of the resident's electronic medical records and Medication Administration History (MAH) revealed multiple instances where administration of prescribed medications, including Hiprex, gabapentin, and carvedilol, was not documented on several dates across January, February, May, and June. The facility's policy requires medications to be administered as prescribed and documented accordingly, but the records showed missing documentation for both morning and evening doses on specific dates. Interviews and policy reviews confirmed that the expectation was for nurses to document medication administration as part of standard care. The Director of Nursing stated that documentation of administered medications is required. The lack of documentation in the resident's records had the potential to result in the resident not receiving accurate care, as there was no evidence to confirm whether the medications were given as ordered.