Failure to Accurately Document Medication Administration for Seizure Management
Penalty
Summary
The facility failed to maintain accurate medication administration records for one resident with a history of seizures. Physician orders required the resident to receive Lamotrigine twice daily and Phenobarbital at bedtime for seizure management. Review of the resident's Medication Administration Record (MAR) for June revealed multiple dates where there was no documentation of the evening doses being administered for both medications. Nurse interviews confirmed that the medications were given as ordered, but the nurse responsible did not document the administration at the time it occurred. The nurse attributed the missed documentation to a heavy and busy assignment, acknowledging that the documentation should have been completed when the medications were administered. The issue was identified by the Director of Nursing (DON) during a review of the MAR, who then educated the nurse on how to amend the MAR to reflect the actual administration. Despite this, the initial failure to document the administration of seizure medications as required by professional standards resulted in incomplete and inaccurate medical records for the resident.