Failure to Accurately Document Medication Administration and Withholding
Penalty
Summary
The facility failed to maintain accurate medical records and documentation for one resident regarding the administration of Cardura, a medication prescribed for hypertension. The resident, who was cognitively intact and required assistance with most activities of daily living, was discharged from the hospital with an order for Cardura. The physician's order for Cardura remained active for over two months, but the medication was not administered during this period. Despite this, the medication administration records (MARs) inaccurately documented that the resident received several doses of Cardura, while other opportunities were marked as 'other/see nurse's notes.' Nursing staff interviews revealed that the medication was not actually administered, and the documentation of administration was done in error. Staff also failed to document the reason for withholding the medication in the electronic medical record (EMR), and there was no official physician hold order for Cardura. Progress notes indicated that the medication was unavailable and that the physician was aware, but this was not consistently or accurately reflected in the MAR or EMR. The DON confirmed that the resident did not receive any doses of Cardura and that the medication had never been delivered to the facility. The facility's policy required that medication administration be documented as per physician order and that any withheld drugs be appropriately documented on the MAR. In this case, the staff did not follow these procedures, resulting in inaccurate records and a lack of clear documentation regarding the resident's medication status. The breakdown in process led to discrepancies between what was recorded and what actually occurred regarding medication administration.