Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records and properly document medication administration for one resident with multiple diagnoses, including type two diabetes, GERD, anxiety, and dementia. The resident, who had moderately impaired cognition, reported not receiving morning medications and was observed with an untouched breakfast tray. Review of physician orders showed scheduled medications and blood sugar checks, but the Medication Administration Record (MAR) did not indicate that these were administered as ordered or documented at the appropriate times. Interviews with nursing staff revealed that the nurse responsible did not document the administration of the resident's morning medications in the medical record. The unit manager confirmed the lack of documentation and stated that the resident did not receive the medications as scheduled. Further review of the administration history showed that documentation of medication administration was delayed, with entries made significantly after the scheduled times. Consulting staff and the Director of Nurses both stated that medications and blood sugar checks must be administered and documented at the time of administration, which did not occur in this instance.