Falsification of Medication Administration Records for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that registered nurses (RNs) and licensed vocational nurses (LVNs) accurately documented the administration of a psychotropic medication, Seroquel, for a resident with multiple diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. The resident was assessed as having severely impaired cognitive skills and lacked capacity to make medical decisions. The physician ordered Seroquel to be administered three times daily for behavior management, and the care plan directed staff to administer the medication as ordered. Review of the Medication Administration Records (MARs) for November and December showed that staff documented Seroquel as administered or refused on multiple occasions when the medication was not actually available in the facility. Progress notes indicated that the medication was not administered at several scheduled times due to pending pharmacy delivery, yet the MARs reflected administration or refusal entries. Interviews with nursing staff confirmed that they documented administration or refusal despite the medication not being present, and did not follow up with the pharmacy to ensure timely delivery. Pharmacy records and interviews revealed that the pharmacy did not receive a request for Seroquel until several days after the order was written, and the medication was not delivered until more than a week later. The facility's policy required medication to be administered and documented in accordance with physician orders and good nursing practice, but this was not followed. As a result, the resident's medical records were inaccurate and did not reflect the actual care provided or the resident's clinical condition during the period in question.