Failure to Accurately Document Medication Administration per Physician Orders
Penalty
Summary
The facility failed to maintain accurate documentation for medication administration for one resident with multiple diagnoses, including quadriplegia and neuromuscular dysfunction of the bladder. The resident had a physician's order for Midodrine 10 mg to be administered three times daily, with instructions to hold the medication if the systolic blood pressure exceeded 120. Review of the Medication Administration Record (MAR) showed that the medication was documented as given on multiple occasions when the resident's systolic blood pressure was above the ordered threshold. Specifically, in November, the medication was recorded as administered 14 times outside the parameters, and in October, 28 times, with several nurses involved in the documentation. Interviews with the assigned RN and the Director of Nursing (DON) confirmed that the MAR contained documentation errors, with the RN acknowledging that she may have checked off the medication as given in error and did not use the appropriate codes for held or not given medications. The DON was unable to provide a reason for the failure to follow the physician's order and acknowledged the expectation for accurate documentation. The facility's policy required corrections to be made in the electronic record, but the errors persisted over multiple months and involved several staff members.