Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records and ensure proper documentation of medication administration for a resident with orders for lidocaine adhesive patches. The resident had a physician's order specifying the application of four 4% lidocaine patches daily to bilateral hips and lower back. However, observations and interviews revealed that nursing staff did not follow the order as written. One nurse consistently applied only two patches, either to the resident's low back or hips, and documented in the Medication Administration Record (MAR) as if all four patches were administered. Another nurse admitted to applying only one patch per administration, despite signing the MAR for four patches, and could not provide a reason for not following the order. Both nurses acknowledged that their documentation on the MAR was inaccurate, as it did not reflect the actual number of patches applied. The Director of Nursing and Assistant Director of Nursing confirmed that the nurses should have clarified the order if they were not administering the medication as prescribed, and agreed that the documentation was not accurate. The deficiency was identified through observations, record reviews, and staff interviews, which demonstrated a pattern of inaccurate documentation and failure to follow physician orders for medication administration.