Failure to Accurately Document Medication Refusals
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, vascular dementia, and other chronic conditions was not properly documented as refusing medication. The resident was prescribed multiple medications, including psychotropics and treatments for chronic illnesses. According to the medication administration report, the resident was documented as having received all prescribed medications during a specific period, while progress notes indicated that the resident had refused all medications during that same timeframe. The LVN responsible for administering the medications admitted to prematurely coding the medications as administered because they had already been pulled from the medication cart, despite the resident refusing to take them. The LVN documented the refusals in the progress notes but did not accurately reflect this in the medication administration record (MAR). This discrepancy was confirmed by interviews with the ADON and another LVN, both of whom stated that medication administration should only be documented after witnessing the resident take the medication, and refusals should be properly coded in the MAR. Facility policy required accurate and timely documentation of medication administration, including verifying medications against physician orders and documenting immediately after administration. The failure to accurately document medication refusals in the MAR resulted in a discrepancy between the MAR and progress notes, which could lead to a lack of awareness regarding the resident's actual medication intake.