Failure to Accurately Document Medication Administration in Resident Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with accepted professional standards and practices, specifically regarding the accurate documentation of medication administration for eight residents. On a specific evening, a Certified Medication Aide (CMA) documented in the Medication Administration Records (MARs) that several residents had received their prescribed evening medications. However, unopened unit-dose medication packages labeled for these residents were later discovered in the medication cart, indicating that the medications had not been administered as documented. Interviews with staff revealed that the CMA responsible for the medication pass stated she had asked the residents if they would take their medications before opening the packages and, upon their refusal, did not administer the medications. She admitted to documenting the medications as given and later forgetting to update the MARs to reflect the refusals. The facility's policy required immediate documentation after medication administration, including reasons for any refusals, but this protocol was not followed. The ADON and other staff confirmed that the MARs inaccurately reflected that medications were administered when, in fact, they were not. The residents involved had significant medical histories, including dementia, mental health disorders, and other chronic conditions, and were prescribed various medications for these diagnoses. The failure to accurately document medication administration and refusals was identified through observation, record review, and staff interviews. The incident was discovered when another CMA found the unopened medications and reported the discrepancy, leading to an internal review and confirmation that the MARs did not accurately represent the care provided.