F0835

E

Improper Use of Shared Computer Login for Medication Administration and Documentation

Kansas City, Missouri Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Administration failed to safeguard medication administration by not ensuring a Certified Medication Technician (CMT) had a functioning, individual computer sign-in to access the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The facility’s Employee Handbook, acknowledged in writing by both the CMT and a Licensed Practical Nurse (LPN), prohibited sharing passwords and falsifying records or signatures, and required compliance with federal False Claims Act provisions. Despite these policies, the CMT reported ongoing problems signing in under CMT credentials, while still being scheduled to pass medications, and ultimately used the LPN’s login to document medication administration for residents.

Human Resources (HR) was responsible for setting up and managing staff computer credentials, including creating sign-ins after background checks and resetting passwords. HR stated that the CMT had been transferred from CNA to CMT credentials and that the CMT’s password had been reset multiple times. HR also reported telling the CMT not to use another staff member’s sign-in, but was not aware the CMT continued to have access issues and was using the LPN’s credentials. The DON stated HR handled credential setup and that staff could contact HR or the DON at any time for sign-in problems, but the DON was unaware the CMT was having ongoing access issues or using another staff member’s sign-in. The Regional Nurse indicated that each staff member should have their own sign-in, staff should not work if they cannot chart, and PRN staff who have not worked in over three months should be made inactive in the system.

The CMT stated that the Administrator, HR, DON, and ADON were all informed on several occasions that the CMT could not sign in as a CMT, only as a CNA, yet the CMT continued to be assigned medication-passing shifts. The CMT described working a shift with the LPN during which the CMT could not chart medications, and the LPN allowed use of the LPN’s sign-in to document in residents’ medical records; the CMT then continued to use the LPN’s sign-in after the LPN went PRN, signing out controlled substances in the narcotic book under the CMT’s own name but documenting administration in the MAR under the LPN’s initials. The LPN, who had not worked since going PRN, denied giving the CMT permission or login information and reported that the computer often remained logged in or displayed passwords, and that the LPN was never asked to change a password. The Administrator, DON, HR, and Regional Nurse all reported they were not aware that the CMT was using the LPN’s sign-in to pass and document medications. This situation had the potential to affect all residents in the facility, which had a census of 74.