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By John A. Brekka, Jr., Esq.
Quintairos, Prieto, Wood & Boyer, P.A.
Assistance with medication administration is a service commonly offered by Assisted Living Facilities (ALFs). Next to allegations of inappropriate placement, improper administration of medication is an area now being pursued by Plaintiffs’ counsel against ALFs.  These types of claims against facilities generally involve two areas: administration of the wrong medication, and/or the failure to document administration of the correct medication.  In all administration assistance cases, documentation becomes the central issue in the case.
The biggest step a facility can take to manage risks is to properly document compliance with the regulations. Each facility should go beyond the four-hour mandated training standards required of unlicensed personnel assisting with the administration of medication and continuously emphasize the need for effective documentation and communication with regard to medication administration.
The reason for this is simple: facilities are required to document compliance. But documentation beyond the Medication Observation Record (MOR) commonly falls by the wayside in the rush of a busy day. The lack of follow up documentation can lead to problems. A facility is required to verify and document when medications are received and when they are dispensed. Facilities need to have a nurse verify that prescriptions received are what the doctor prescribed for the resident.
Additionally, they need to document the assistance provided to the resident in taking the medication(s). While facilities are usually good at charting assistance with medication in the MOR, the most commonly missed area is to further document when a resident refuses to take medications as prescribed. While the resident is free to refuse to take any medication prescribed, when they do refuse, they must be counseled and, their physician must be notified. Documentation of the refusal, the counseling and the physician communication must be maintained. A simple notation in the MOR indicating that “the resident refused”, without more, leaves the facility open to risks.
Documentation not only protects in lawsuits, it also fosters better care of residents. While a review and discussion of all areas required is beyond the scope of this article, continuing attention to documentation detail is an area which should be repeatedly emphasized by in house or outside continuing education of caregivers. If you desire more information on training sessions or seminars, please contact the attorneys at Quintairos, Prieto, Wood & Boyer, P.A.
The information contained in this article is not intended to be legal advice or intended as a substitute for legal advice.  Please discuss any information gathered from this article with your legal counsel in the context of your particular situation before implementing new policies or procedures.
About the Author
John A. Brekka, Jr.
is the Managing Partner of the Firm’s Ft. Lauderdale Office and is also appellate counsel for the Firm. His areas of practice include nursing home, assisted living and medical malpractice defense, professional liability defense, banking, securities and complex commercial litigation.  Mr. Brekka is admitted to practice law in the states of Florida, Georgia and Mississippi.  He is admitted to practice before the United States Supreme Court, the 5th and 11th Circuit Courts, U.S. Tax Court and all Federal District Courts in Florida and Mississippi.


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