Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by not documenting medication administration in accordance with accepted professional standards. Specifically, a registered nurse administered at least six different medications to the resident more than two hours before the scheduled 09:00 AM time, but did not document the administration until approximately 08:50 AM, which was only ten minutes before the medications were due. The nurse confirmed that the medications were given early and that the documentation did not reflect the actual time of administration, as the electronic health record system did not allow for documentation more than one hour before the scheduled time. Observations at the resident's bedside confirmed the presence of the medications on the table, and interviews with both the nurse supervisor and the Director of Nursing verified that facility policy requires medications to be administered no more than one hour before or after the scheduled time and that documentation should occur immediately after administration. The inaccurate documentation made it appear as if the medications were given on time, when in fact they were not, and this was acknowledged by both the nurse and the Director of Nursing as not aligning with facility and nursing standards.