Failure to Accurately Document Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was properly informed of, and participated in, their treatment regarding the administration of antipsychotic medication. Specifically, for a resident with severe cognitive impairment and multiple psychiatric diagnoses, the June Medication Administration Record (MAR) did not reflect that RisperDAL Consta was administered on two scheduled dates. The MAR entries for these dates were left blank, despite the medication being given according to the Director of Nursing (DON). The resident's care plan included interventions for medication refusal and behavioral issues, and the responsible party (RP) confirmed ongoing communication and consent for the medication. Interviews and record reviews confirmed that the facility's policy required staff to initial the MAR after administering each medication, but this was not done for the two identified dates. The DON acknowledged the importance of accurate MAR documentation to ensure staff are aware of what medications have been administered. The lack of proper documentation could result in residents not being fully informed or involved in their treatment as required.