Inaccurate Medication Administration Documentation
Penalty
Summary
Licensed nursing staff failed to maintain complete and accurate medical records for a resident by signing the Medication Administration Record (MAR) for an antibiotic therapy on three separate dates, despite the medication not being delivered to the facility on those dates. The MAR inaccurately indicated that the resident received Fidaxomicin for C-diff infection on those days, when in fact the medication was not available until several days later. This discrepancy was identified during a review of the resident's records and confirmed through interviews with nursing staff and the facility's pharmacist, who stated the antibiotic was first delivered several days after the MAR entries indicated administration. The resident involved had multiple complex medical diagnoses, including multiple sclerosis, sepsis, urinary tract infection, a stage three pressure ulcer, and neuromuscular dysfunction of the bladder. The resident was cognitively intact but dependent on staff for activities of daily living. The facility's policy required prompt, complete, and accurate documentation of care, but this was not followed, resulting in the medical record reflecting care that was not actually provided.