Inaccurate Medication Administration Records Due to Improper Delegation
Penalty
Summary
Facility staff failed to maintain accurate medical records and safeguard resident-identifiable information for one resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including medication administration. The resident's physician orders included multiple daily and twice-daily medications for various conditions, such as recurrent urinary tract infections, vaginal candidiasis, and chronic health issues. Despite these orders, nursing staff, including an RN and an LPN, reported that they routinely provided the resident's medications to the resident's Power of Attorney and private caregivers, rather than administering the medications themselves. Both staff members admitted to signing the Medication Administration Record (MAR) as if they had administered the medications, even though they could not confirm the medications were actually given to the resident. The facility's policy required that nurses document medication administration in the MAR immediately after personally administering the medication to each resident. The policy also specified that medications must be administered by legally authorized and trained persons in accordance with applicable laws and accepted standards of practice. The interim Director of Nursing confirmed that staff are expected to document only the work they perform and to ensure that medications are administered before signing the MAR. The actions of the nursing staff, as described in interviews and record reviews, were inconsistent with both facility policy and professional standards, resulting in inaccurate medical records for the resident.