Failure to Accurately Document Medication Administration in Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents regarding the administration of the antibiotic Cefdinir. For one male resident with diagnoses including encephalopathy, acute cholecystitis, and sepsis, there were ten undocumented occasions of scheduled Cefdinir administration. Review of the Medication Administration Record (MAR) showed multiple blank entries for scheduled doses, particularly for morning administrations, while evening doses were documented as given. Staff interviews revealed uncertainty about whether blanks indicated missed doses or simply missed documentation, with one LPN admitting she may have failed to record the administration despite believing the medication was given. There were also instances where 'see progress note' was entered in the MAR, but no corresponding progress note was found in the resident's record. For a female resident with severe cognitive impairment and diagnoses including sepsis, acute respiratory failure with hypoxia, and pneumonia, there was one occasion where the scheduled administration of Cefdinir was left blank in the MAR. All other scheduled administrations were documented as given. The staff member responsible for this administration was noted to have given other medications at the same time, but no documentation was provided for the antibiotic dose in question. Attempts to interview the staff member were unsuccessful. Facility policy requires that the MAR be signed after medication administration and that any discrepancies be corrected and reported to the nurse manager. The policy also mandates that each resident's medical record accurately reflect the resident's experiences through complete, accurate, and timely documentation. The failure to document medication administration as required resulted in incomplete medical records for both residents.