Failure to Timely Document Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to document the administration of seven scheduled medications for a resident with a history of cerebral infarction, hemiplegia, and diabetes. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, had medications scheduled for 9:00 a.m. that were not documented as given in the Medication Administration Record (MAR). During an interview and record review, the LVN confirmed that the medications were administered but not documented due to being busy, and acknowledged that documentation should occur at the time of administration. The facility's policy and procedure for administering medications requires the individual administering the medication to initial the MAR after giving each medication and before administering the next. The lack of timely documentation resulted in no indication that the resident received the medications, as evidenced by the MAR showing the medications in red, which signifies they were late or not given. This failure to document as required constituted the identified deficiency.