Failure to Accurately Document Medication Administration Times
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices, specifically regarding the accurate documentation of medication administration for three residents. For one resident with bacteremia, diabetes, and hypertension, the Medication Administration Record (MAR) showed multiple instances where the scheduled 7 a.m. dose of intravenous cefazolin was administered late, with times ranging from over an hour to more than three hours past the scheduled time. Despite these delays, the MAR sometimes included comments indicating the medication was given on time, while other entries noted the late administration. The resident reported receiving antibiotics late or early at times. Another resident with septicemia, congestive heart failure, and a history of stroke had a physician's order for daily intravenous ceftriaxone at 9:00 a.m. The MAR indicated that on two occasions, the medication was administered more than an hour late. Similarly, a third resident with Crohn's disease, ileocecal resection, and an ileostomy had a physician's order for daily intravenous fluconazole at 9:00 p.m., but the MAR showed the medication was administered over an hour late on one occasion. Interviews with the RN and DON confirmed that the MARs reflected late administration times, and both acknowledged that medication administration should be documented accurately and timely, with the MAR reflecting the actual time of administration. Facility policies reviewed stated that charting should be factual, accurate, and timely, and that medications should be administered within 60 minutes of the scheduled time, with immediate documentation following administration.