Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for a resident with multiple diagnoses, including end stage renal disease, type two diabetes mellitus, depression, and hypertension. The resident had a physician's order for Coreg, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mm Hg. Review of the Medication Administration Record (MAR) showed that on three occasions, the resident's SBP was below the specified threshold, yet the MAR indicated that the medication was administered. During interviews, the registered nurse responsible for the resident on those dates stated that she did not actually administer the Coreg when the SBP was below parameters, but believed that documenting the low blood pressure was sufficient to indicate the medication was held. The nurse was unaware that the electronic charting system provided a specific code to document medications held due to parameters. The Director of Nursing confirmed that the MAR did not accurately reflect that the medication had been held according to the physician's order.