Inaccurate Medication Administration Documentation Prior to Medication Receipt
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed during a complaint survey. The resident, admitted with multiple diagnoses including cerebral infarction with hemiplegia and hemiparesis, aphasia, and several psychiatric conditions, experienced a change in condition when redness was noted in the left eye. A new order for Polyethylene glycol eye drops was placed, but documentation in the electronic Medication Administration Record (eMAR) indicated that the medication was signed off as administered on several occasions before it was actually delivered to the facility. Interviews with nursing staff and review of the medication audit details confirmed that three nurses documented administration of the eye drops prior to their arrival at the facility. The LPN involved could not recall the specifics and acknowledged the possibility of documentation error. The Director of Nursing and Nursing Home Administrator both confirmed that the medication was not available at the time it was documented as given, resulting in inaccurate and incomplete medical records for the resident.