Inaccurate Medication Administration Documentation
Penalty
Summary
Facility staff failed to ensure the accuracy of a resident's medical record by documenting that a medication was administered by nursing staff when, in fact, the resident had self-administered the medication without nursing supervision. The resident, who had diagnoses including dysphagia following cerebral infarction, type two diabetes, and hemiplegia affecting the non-dominant side, required assistance with self-care and mobility and did not have an order to self-administer medications. Despite this, the resident was able to access and use a prescribed nasal spray independently, as the medication had been left at the bedside by the night shift. During a medication pass, an LPN prepared the resident's medication and entered the room, only to find that the resident had already used the nasal spray. The LPN subsequently signed the medication administration record (MAR) as if the medication had been administered by the nurse, contrary to facility policy, which requires staff to document only medications they have personally administered. The DON confirmed that the nurse should not have documented the medication as given when it was not witnessed.