Failure to Accurately Document Medication Administration in Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for two residents. For one resident with severe cognitive impairment and a diagnosis including gastro-esophageal reflux disease, staff did not document the administration of Protonix on the electronic medication administration record (eMAR) as required. Although nursing notes indicated the medication was given while the resident was waiting for dialysis, the eMAR entry for the scheduled time was left blank. The nurse responsible later acknowledged in a written statement that the medication was administered but the eMAR was not signed immediately due to oversight. For another resident, who was cognitively intact and admitted with diagnoses including nerve damage and chronic pain, staff failed to accurately document the administration of Oxycodone on the Controlled Drug Administration Record. The eMAR showed that the resident received the medication at two scheduled times, but the corresponding entries were missing from the controlled substance log. The DON confirmed that the nurse forgot to document the administration on the controlled drug record as required. Both deficiencies were identified through staff interviews and clinical record reviews. The failures involved not immediately documenting medication administration in the appropriate records, as confirmed by staff and administrative interviews. No additional information or documentation was provided by facility leadership prior to the survey exit.