Failure to Accurately Document Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to accurately document the administration of apixaban, an anticoagulant, for a resident with diagnoses including sepsis, end stage renal disease, and diabetes mellitus type II. The resident was admitted with an order for apixaban to be given twice daily for deep vein thrombosis prophylaxis. On the morning in question, the LVN marked the medication as administered on the Medication Administration Record (MAR), despite the medication still being present in the bubble pack and not actually given to the resident. The LVN was unable to explain why the medication was documented as given when it had not been administered. Further review by facility leadership confirmed that the resident was out for dialysis at the time the medication was marked as given, and there was no nursing note explaining the discrepancy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both acknowledged that the MAR should accurately reflect medication administration and that signing for a medication not given creates a discrepancy in the medical record. Facility policy requires all services and changes in condition to be documented completely and accurately to facilitate communication among the care team.