Inaccurate Medication Administration Documentation for Absent Resident
Penalty
Summary
The facility failed to maintain accurate medical records for one resident who was reviewed for resident records. The resident, a male with a history of stroke and intact cognition, was documented as having left the facility with family and did not return. Despite this, the Medication Administration Record (MAR) showed that multiple medications were documented as administered to the resident on several dates after he had already left the facility. There were no nursing progress notes indicating the resident's return after his departure, and interviews with staff and the resident's family confirmed that he did not return to the facility during this period. Medication aides and nursing staff reported that they documented medication administration in the electronic medical record after giving medications, but could not recall if the resident was present at the time of documentation. The Director of Nursing and Unit Manager confirmed that staff were expected to chart medications immediately after administration and to ensure the resident was present. The facility's policy required staff to flag the MAR if a resident was not present and follow specific guidelines, which was not done in this case. This resulted in inaccurate documentation of medication administration for a resident who was not in the facility.