Incomplete Medication Administration Record Documentation
Penalty
Summary
Facility staff failed to ensure a complete and accurate clinical record for one resident, as required by professional standards. Specifically, the Medication Administration Record (MAR) for a resident with diagnoses including dementia, peripheral vascular disease, neuropathy, and diabetes was not documented for several scheduled doses of Gabapentin. The MAR lacked documentation for the 2:00 p.m. and 9:00 p.m. doses on one day, and the 9:00 a.m. and 2:00 p.m. doses on the following day. The resident was assessed as cognitively intact at the time of the incident. During the investigation, the facility's nurse consultant confirmed that the nurse responsible for medication administration on the days in question was no longer employed at the facility. Although a narcotic sign-out sheet indicated the medication was distributed, the MAR did not reflect that the medication had been administered as required. Facility policy mandates that the individual administering medication must document the administration on the MAR immediately after giving the medication and review the MAR at the end of each pass to ensure all doses are properly recorded.