Failure to Immediately Document Medication Administration on MAR
Penalty
Summary
A registered nurse failed to immediately document the administration of scheduled medications on the Medication Administration Record (MAR) for a resident with diagnoses including type 2 diabetes mellitus and hypertension. The resident was prescribed amlodipine, ClearLax, and Paxlovid, all scheduled for administration at 9 a.m. On the day in question, there was no documentation on the MAR to indicate whether these medications were given at the scheduled time. Upon review, it was found that the nurse documented the administration, refusal, or holding of these medications several hours after the actual events occurred. The nurse acknowledged not following the facility's established process of pouring, passing, and immediately documenting medication administration. Both the nurse and the Director of Nursing confirmed that immediate documentation is required to communicate which medications have been administered, held, or refused. The facility's policy also specifies that the individual administering the medication must initial the MAR after giving each medication and before administering the next. The delay in documentation created a situation where it appeared the resident had not received their scheduled medications.