Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to ensure that medical records were updated and accurate for one resident. Review of the resident's face sheet confirmed admission to the facility, and a provider order indicated that Imodium A-D was to be administered as needed for diarrhea. On review of the medication administration record (MAR), it was found that no Imodium A-D had been documented as given by midday, despite an LPN stating during interview that she had administered the medication during the morning medication pass. The LPN acknowledged that she had not documented the administration due to being very busy and intended to document it later. The Director of Nursing confirmed that all medications should be documented immediately after administration, and that there should be no delay between giving and documenting medications.