Incomplete Medication Administration Documentation in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurate and complete, specifically regarding the documentation of medication administration. According to facility policy, the individual administering medication is required to initial the Medication Administration Record (MAR) after giving each medication and before administering the next. Additionally, all services provided, progress toward care plan goals, and any changes in the resident's condition must be documented in the medical record to facilitate communication among the interdisciplinary team. For one resident, the MAR for November showed that multiple prescribed medications, including a multivitamin-mineral supplement, lactobacillus, famotidine, and Docuprene, were not documented as administered on a specific date. Interviews with nursing staff confirmed that the MAR lacked documentation for these medications, despite reports from the resident's family and staff observations that the medications had been prepared and given. The nurse responsible did not recall missing any doses, but the MAR was not signed, and no progress note was entered to confirm administration. The Director of Nursing acknowledged that the nurse should have documented the medication administration in the MAR and entered a progress note, as required by facility policy.