Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for one of three sampled residents. Specifically, a registered nurse supervisor administered Benadryl 25 mg orally to a resident but did not document the administration on the Medication Administration Record (MAR) at the time the medication was given. The omission was confirmed during an interview with the nurse, who acknowledged that documentation should have occurred immediately after the medication was administered. Observation confirmed that the resident received the medication, but the corresponding entry on the MAR for that date was left unsigned. The resident involved had a history of generalized muscle weakness, hypertension, and dementia, and was assessed as having intact cognition. Facility policy required that the individual administering medication must initial the MAR after giving each medication and before administering the next, including recording the date, time, dosage, route, symptoms, and the signature and title of the person administering the drug. The failure to document the administration of Benadryl was contrary to this policy and was identified through both record review and staff interview.