Failure to Document Medications Given in Error in Resident Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who received another resident's medications in error. The resident was admitted on an unspecified date and experienced a medication variation on the night of 11/06/25, when the assigned nurse administered medications intended for a different resident. A Change in Condition form completed by the DON on 11/06/25 documented that a medication variation had occurred, included the resident's vital signs, allergies to penicillin and tuberculin solution, and noted there were no changes in the resident's mental, physical, or behavioral status. The form also documented that the resident, who was his own responsible party, and the on-call physician service were notified, and that the physician ordered monitoring for changes. Despite this, the medical record contained no documentation specifying which medications were given in error. The Change in Condition form did not list the medications administered by mistake, and there was no other documentation in the record identifying them. Supervisor #9 reported that the nurse who made the error had informed her that she had given the resident another resident's medications, but stated she did not document the medications because she believed the responsibility lay with the nurse who made the error. The DON confirmed that neither the nurse nor the supervisor documented the specific medications given in error and acknowledged that this information should have been entered into the medical record at the time of the incident and included on the Change in Condition form.
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