Medication Administration Documented Prior to Receipt
Penalty
Summary
Licensed nursing staff failed to meet professional standards of practice by documenting the administration of a medication before it was actually available in the facility. Specifically, a resident with multiple diagnoses, including cerebral infarction with hemiplegia, aphasia, and psychiatric disorders, was ordered to receive Polyethylene glycol eye drops for redness and dryness in the left eye. The medication was ordered and documented as not given on the first scheduled dose, with a corresponding note explaining the delay due to pharmacy delivery. However, subsequent doses were signed off as administered by nursing staff, despite the medication not being delivered to the facility until several days later. Interviews with the LPN who signed off on the administration and the DON confirmed that multiple nurses documented the medication as given when it had not yet been received. The audit trail in the electronic medical record verified that the medication was not dispensed to the facility until after the dates it was documented as administered. The NHA was made aware of the issue and acknowledged the concern during the surveyor's investigation.