F0842

E

Improper Medication Documentation Using Another Nurse’s Electronic Login

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that medications and treatments were documented on the MAR and TAR by the person actually administering them, as required by the facility’s Medication Administration Policy. The policy stated that the licensed nurse or CMT must chart the drug, time administered, and initial his/her name with each medication administration, and that documentation must be completed by the person who administers the drug or treatment. Contrary to this policy, for approximately three months, a CMT used an LPN’s electronic sign-in to document medication administration for multiple residents, resulting in inaccurate attribution of who administered medications and treatments.

The residents affected included individuals with multiple chronic and serious conditions such as dementia, Alzheimer’s disease, COPD, chronic kidney disease (various stages), hypertension, hyperlipidemia, major depressive disorder, anxiety, hypothyroidism, chronic pain, neuropathy, peripheral vascular disease, diabetes type II, cerebrovascular disease, stroke, malignant neoplasm of the head/face/neck, diverticulosis, depression, and delusional disorder. These residents were admitted or readmitted on various dates and were receiving ongoing medication and treatment regimens documented in their MARs and TARs. Review of the facility’s MARs and TARs for November 2025, December 2025, and January 2026 showed that medications and treatments were recorded as being administered by the LPN on numerous dates to at least eight sampled residents, even though timecard records showed the LPN had not worked at the facility after a specific date in late November and had gone to PRN status.

Interviews and record reviews revealed how the misdocumentation occurred. The CMT reported that after becoming certified in October 2025, he/she had ongoing problems signing into the electronic system as a CMT and could only sign in under CNA credentials, which did not allow access to the MAR/TAR for medication charting. The CMT stated that he/she informed the Administrator, HR, DON, and ADON on several occasions that the sign-in problem persisted, but it was not corrected, and HR continued to schedule the CMT to pass medications. The CMT said that while working a shift with the LPN, he/she was unable to chart medications, and the LPN allowed him/her to use the LPN’s sign-in to document medication administration. The CMT then continued to use the LPN’s sign-in to chart medications after the LPN went PRN, signing out controlled substances in the controlled drug book under his/her own name but documenting administration in the electronic record under the LPN’s initials. HR confirmed that the CMT had an existing sign-in from CNA status, that passwords had been reset multiple times, and that the CMT had stated he/she could use another staff member’s sign-in, which HR said was not permitted. The Administrator stated he/she was not aware the CMT was having sign-in issues or using the LPN’s credentials, and that staff were not to share passwords. The LPN stated he/she was not aware the CMT was using his/her sign-in, did not give permission or share login information, and described that the computer system sometimes remained logged in or displayed passwords and did not require password changes during his/her employment.