Failure to Document Medication Administration in MAR
Penalty
Summary
A deficiency occurred when the facility failed to ensure that medication administration was properly documented in the Medication Administration Record (MAR) for a resident. The resident, who was admitted with multiple diagnoses including pneumonia, diabetes, gastrostomy status, dependence on supplemental oxygen, and heart failure, had severely impaired cognition and was dependent on staff for all activities of daily living. The resident had an active order for Ondansetron 4 mg via G-tube every eight hours as needed for nausea and vomiting. On a day when the resident experienced vomiting, a registered nurse stated that Ondansetron was administered but this administration was not documented in the MAR for that month. Both the registered nurse and the Director of Nursing confirmed that medication administration should always be documented according to facility policy. Review of the facility's policy confirmed that licensed personnel are required to document all medication administration.