Failure to Follow Professional Standards for Medication Documentation
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow professional standards for medication documentation for a resident with multiple complex medical conditions, including aortic valve stenosis, congestive heart failure, diabetes, and vascular dementia. During a medication pass, the LPN prepared the resident's medications and documented their administration in the Medication Administration Record (MAR) before the resident actually received them. The resident initially refused to take the medications until after using the bathroom, prompting the LPN to label the medication cup and store it in the medication cart. The LPN then left the medication cart unlocked and unattended while preparing another resident's medication, only returning to lock it a few minutes later. The resident eventually took the medication after notifying the LPN that she was ready. However, the MAR reflected that the medications had been administered at an earlier time, prior to actual administration. Facility policy and the Director of Nursing's expectations require that medication administration be documented only after the medication has been given to the resident. The LPN's actions did not align with these standards, resulting in inaccurate documentation of medication administration.