Falsification of Medication Administration Record for Anticoagulant Therapy
Penalty
Summary
Facility staff failed to ensure accurate documentation of medication administration for a resident who was admitted with a displaced intertrochanteric fracture of the right femur and a fracture of the right lower leg. The resident was cognitively intact but dependent on staff for activities of daily living. Physician orders required the resident to receive Heparin injections subcutaneously every eight hours for DVT prophylaxis. On a specified date, the Medication Administration Record (MAR) indicated that the resident was not available for her scheduled Heparin dose at 2 p.m. due to participation in therapy, and a subsequent audit report showed documentation of administration at 2:18 p.m., with later changes to the record. The resident reported to another nurse that she did not receive her afternoon Heparin dose after returning from therapy. The second nurse reviewed the MAR, which showed the dose as given, and upon contacting the original nurse, confirmed that the dose had not been administered. The resident experienced swelling in her left leg later that shift, which was assessed and reported to the registered nurse and physician. Interviews with the involved nurse revealed that he had not administered the medication because the resident was not present and that he had erroneously documented the administration in the MAR. He also admitted to making further inaccurate edits to the medical record at a later date. The Director of Nursing confirmed that the nurse admitted to both failing to administer the medication and documenting it as given. Facility policy required that the MAR be signed only after medication administration, which was not followed in this instance. The inaccurate documentation resulted in an incorrect depiction of the resident's medication management and had the potential to disrupt continuity of care.