Failure to Accurately Document Medication Administration and Resident Falls
Penalty
Summary
The facility failed to accurately document medication administration and resident incidents in accordance with accepted professional standards. For two residents, staff documented on the Medication Administration Record (MAR) that medications were given when, in fact, they were not administered. In one instance, a Certified Medication Technician (CMT) did not provide prescribed medications for diabetes and constipation because they were unavailable or not found, yet still recorded them as given. In another case, a CMT failed to administer potassium chloride, thiamine, and aspirin, but documented these medications as administered in the electronic medical record. Interviews confirmed that staff believed signing off on the MAR indicated the medications were given, regardless of actual administration. Additionally, the facility did not document a resident's fall and subsequent hospital transfer in the progress notes or care plan. The resident reported falling while being weighed, resulting in a hip fracture and hospital admission. Although the incident was verbally reported and the nurse assessed the resident, there was no written documentation of the fall or transfer in the resident's medical record. The facility's policy did not specify documentation procedures for falls, and the care plan lacked information on the resident's fall history or transfer status.