Failure to Document Medication Administration in MAR
Penalty
Summary
The facility failed to ensure that a resident's medications were properly documented as administered according to physician orders. During a review of medication administration records (MARs) for one resident with multiple diagnoses, including Dementia, Asthma, Bipolar Disorder, Chronic Diastolic Heart Failure, and Major Depressive Disorder, surveyors found missing entries of nurses' signatures, initials, or codes for several scheduled medications. Specifically, on a certain date and time, there were no documented entries for the administration of Levothyroxine Sodium, Pantoprazole Sodium, and Advair Diskus, all of which were ordered to be given in the morning. The absence of documentation was confirmed by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who stated that nurses are responsible for administering medications and documenting their administration in the electronic MAR. Codes are available for situations such as resident refusal or absence, but blank spaces indicate that the medication was not administered. Facility policy requires that after medication is administered, the MAR must be signed to confirm administration. The Registered Nurse job description also mandates completion of medical records documenting care provided, in accordance with nursing policies and confidentiality standards. The failure to document medication administration as required was observed during the survey and confirmed through staff interviews and policy review.