Failure to Document Missed Medication Dose in Medical Record
Penalty
Summary
Facility staff failed to maintain the accuracy of a resident's medical record by not documenting the reason for a missed dose of medication. During a complaint survey, a resident reported not receiving their prescribed Vitamin C medication for several days. Review of the medical record showed an active order for Vitron-C Oral Tablet to be administered every other day for anemia. Examination of the Medication Administration Record (MAR) revealed that on one date, the nurse's initials were accompanied by the number '9', which, according to the MAR legend, indicated 'See Nurse Note.' However, upon request, the Director of Nursing (DON) was unable to locate any corresponding nurse note or documentation explaining whether the medication was given or the reason for the missed dose. The absence of this documentation in the medical record was acknowledged by the DON.