Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate and complete documentation of medication administration for two residents. For one resident, physician orders indicated acetaminophen was to be administered for pain following a fall. Nursing progress notes documented that the medication was given on multiple occasions, but the Medication Administration Record (MAR) did not reflect administration on all relevant dates. The nurse involved could not recall the specific days the medication was administered and acknowledged that the MAR should have been signed if the medication was given. For another resident, there was a physician order for tramadol to be administered as needed for pain. After a fall resulting in pain, the controlled substance count sheet showed that tramadol was administered, but the MAR did not document this administration. The nurse responsible confirmed that she gave the medication but could not recall the time and stated she must have forgotten to document it on the MAR. The administrator confirmed that medication administration should be accurately documented on the MAR.