Failure to Timely Document Medication Administration on MAR
Penalty
Summary
The facility failed to ensure that a licensed nurse documented the administration of levetiracetam, an anti-seizure medication, on the Medication Administration Record (MAR) immediately after giving the medication to a resident. The resident in question had a history of intracerebral hemorrhage, seizure disorder, and required gastrostomy feeding due to dysphagia. The resident was severely cognitively impaired and dependent on staff for all activities of daily living. Review of the resident's electronic MAR revealed multiple instances where the documentation of medication administration was recorded significantly later than the scheduled time, with some entries made hours after the medication was due. Interviews with nursing staff confirmed that although the medication was reportedly administered within the allowed window, documentation was delayed to save time during medication passes. Both the LVN and RN involved acknowledged that documentation should occur immediately after administration, as per facility policy, but admitted to late entries. The Director of Nursing also confirmed that immediate documentation is required to avoid confusion regarding medication administration times. Facility policy reviewed indicated that medications should be administered and documented within 60 minutes of the scheduled time, except for specific meal-related orders.