Failure to Timely Document Medication Administration
Penalty
Summary
A deficiency was identified when a physician-ordered medication for a resident was not signed as administered at the time of administration, contrary to professional standards of practice. The resident, who had diagnoses including acute right heart failure, diabetes, major depressive disorder, and muscle weakness, was cognitively intact according to a recent assessment. The medication in question was levothyroxine sodium, ordered to be given orally each morning for hypothyroidism. Review of the Medication Administration Record (MAR) for September revealed that the administration entry for a specific morning dose was left blank. Further investigation showed that the MAR was later signed for this dose several weeks after the scheduled administration date, as confirmed by the Medication Admin Audit Report. The LPN responsible for administering the medication stated during interview that she had given the medication but forgot to sign the MAR at the time. Facility policy requires that the individual administering medication must initial the MAR immediately after giving each medication and before administering the next. The DON confirmed that the expectation is for medication administration to be documented at the time of administration.