Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, two LVNs did not document the administration of prescribed clonazepam and insulin on multiple occasions, as evidenced by missing check-offs on the Medication Administration Record (MAR) for several dates. There was no documentation in the progress notes to indicate whether the medications were administered, held, or refused on those dates. The resident involved was an adult male with multiple diagnoses, including Parkinson's disease, type 2 diabetes, intellectual disabilities, autistic disorder, anxiety disorder, and depression. Physician orders required the administration of clonazepam three times daily for anxiety and insulin as per a sliding scale for diabetes. Review of the MAR for the relevant month showed that doses of both medications were not documented as given at several scheduled times. Interviews with the LVNs responsible revealed that they administered the medications as ordered but failed to document the administration on the MAR, attributing the omission to forgetfulness. Both LVNs acknowledged their responsibility to ensure accurate documentation and confirmed that the resident did not refuse medications and was not out of the facility. The facility's policies required documentation of all administered medications and specific procedures for documenting refusals, which were not followed in these instances.