Inaccurate Medication Administration Documentation for Absent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that resident records were complete and accurately documented regarding medication administration for a resident who left the facility. The resident, who had diagnoses including aftercare following a hip replacement, post-traumatic stress disorder, and osteoarthritis, was admitted in May 2025 and had intact cognition as evidenced by a Brief Interview for Mental Status score of 14 out of 15. A physician's order was in place for Acetaminophen 325 mg, two tablets three times daily. The Medication Administration Record (MAR) showed that the 2:00 PM dose of Acetaminophen was documented as administered on 5/29/2025 by an LPN. However, the resident reported leaving the facility around 11:00 AM on the same day and did not return. The LPN initially believed the resident was present in the room at 2:00 PM and had eaten lunch, but later acknowledged being unaware that the resident had left earlier and admitted that the documentation of the 2:00 PM medication administration was inaccurate. The Director of Nursing Services confirmed that medications should only be documented as administered if actually given and could not explain the discrepancy in the record.