Failure to Timely Document Medication Administration
Penalty
Summary
The facility failed to ensure timely and accurate documentation of medication administration for one resident out of three reviewed. The resident in question had multiple complex diagnoses, including osteomyelitis, spinal cord injury, sepsis, and paraplegia, and was cognitively intact. Review of the resident's electronic Medication Administration Record (MAR) for July and August revealed numerous instances where medications were not signed as administered, leaving blank spaces for several medications across multiple dates. Further investigation showed that the corresponding printed MARs for July had manual initials added after the fact, and the electronic MARs for August were signed off electronically at a much later date. Interviews with nursing staff and facility leadership confirmed that medications had been administered but were not documented at the time of administration. Staff reported forgetting to sign off on the MARs and later completed the documentation after being approached by facility management. Facility policy requires that the individual administering medications must record the administration directly after giving the medication and review the MAR at the end of each pass to ensure all doses are documented. The policy also states that no staff should leave duty without recording all medication administrations. The failure to document medication administration as required by policy and professional standards led to the identified deficiency.