Inaccurate Medication Administration Times Documented in MARs
Penalty
Summary
The facility failed to ensure that pre-poured medications were administered in a timely manner and that medication administration records (MARs) accurately reflected the actual times medications were given. During observation and interviews, a staff member was found to have pre-poured medications for multiple residents and stored them in a locked medication cart drawer. The staff member scanned the medications into the MAR as if they had been administered at that time, even though the medications were not actually given until later. The staff member admitted to sometimes changing the administration time in the MAR to match the actual time, but on the day of observation, did not do so due to being late and running behind. The staff member also indicated that this practice occurred more frequently when the facility was short-staffed and acknowledged that this method was incorrect. Specific instances were observed where residents received their medications at times that did not match the times documented in their MARs. For example, one resident received medications at 8:14 a.m., but the MAR showed administration at 7:32 a.m.; another received medications at 8:19 a.m., with the MAR indicating 7:38 a.m.; and a third resident received medications at 8:28 a.m., while the MAR documented 8:03 a.m. These discrepancies resulted in inaccurate documentation of medication administration times for at least three residents. Staff interviews confirmed that this practice was unacceptable and did not meet professional standards of quality.