Failure to Document Medication Administration in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple chronic conditions, including dementia, hypertension, hyperlipidemia, and congestive heart failure. On a specific date, the Medication Administration Record (MAR) for this resident showed missing documentation for several prescribed medications, including Atorvastatin, Donepezil, Apixaban, Carvedilol, Oxybutynin, Sacubitril-Valsartan, and Mirtazapine, all of which were to be administered via PEG-tube. The absence of documentation was noted for the evening medication schedule, despite physician orders requiring these medications. Interviews with the Director of Nursing (DON) and the nurse responsible for medication administration revealed conflicting accounts. The nurse stated she administered and documented the medications, attributing the missing records to a possible system glitch in the electronic medical record (PCC). However, the DON confirmed that the nurse admitted to forgetting to document the administration initially, and later claimed to have completed the documentation. The facility's policy requires all medication administration or refusals to be documented in the MAR or TAR, with no blanks permitted. Further review of the facility's policies and additional staff interviews confirmed that all medication administration must be recorded, and that failure to do so could result in miscommunication or medication errors. The resident involved was unable to recall whether the medications were received, and no changes in condition were observed following the incident. The deficiency was identified through review of records and staff interviews, which confirmed the lack of required documentation for medication administration.