Incomplete Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident. The resident, who was admitted with a left femur fracture and prostate cancer with bone metastasis, had a physician's order for apalutamide, a hormone blocker used to treat prostate cancer. On a specific date, the Medication Administration Record (MAR) indicated with code 9 that additional details regarding the administration of apalutamide should be referenced in the Progress Notes. However, a review of the Nursing Progress Notes revealed there was no documentation about the administration of the medication on that date. During an interview, an LPN recalled being unable to initially locate the cancer medication, but after a family member identified its location in the medication cart, the LPN administered it to the resident. The LPN was unsure if she documented the administration in the nurses' notes, despite having marked code 9 on the MAR. The Director of Nursing confirmed that the nurse should have either documented the medication as given or provided an explanation in the nurses' notes. The facility's policy requires documentation of medication administration or refusal as per facility guidelines.