Failure to Document Medication Administration and Refusals on MAR
Penalty
Summary
A deficiency occurred when a licensed nurse failed to accurately document the administration and refusal of medications for a resident with quadriplegia, muscle wasting, and anxiety disorder. The resident, who had intact cognition and was dependent on staff for most activities of daily living, had several scheduled medications due during an evening shift. The Medication Administration Record (MAR) for that shift was left blank, with no indication of whether the medications were administered or refused. Interviews revealed that the resident often experienced confusion regarding which nurse would administer evening medications and frequently refused most of them, only accepting simethicone on the shift in question. The nurse assigned to the resident offered the medications, documented that only simethicone was taken, and reported being distracted by an emergency, which led to forgetting to document the administration and refusals on the MAR. Facility policy required immediate documentation of medication administration or refusal, which was not followed in this instance.