Failure to Document Medication Administration on MAR
Penalty
Summary
Facility nursing staff failed to consistently document medication administration on the Medication Administration Record (MAR) for two residents. For one resident with diagnoses including major depressive disorder, anxiety disorder, and asthma, there was a blank entry on the MAR for a scheduled dose of Tylenol Extra Strength, and no corresponding documentation in the progress notes to indicate whether the medication was administered. For another resident with anemia, diabetes, and hypertension, blank spaces were found on the MAR for scheduled applications of Clobetasol Propionate cream, with no documentation in the progress notes to confirm administration. Interviews with the LPN and the Director of Nursing confirmed that facility policy requires nurses to sign the MAR after administering medications and to document refusals or held medications with appropriate codes, ensuring no blank spaces are left. Both staff members acknowledged that the MARs for the two residents contained blank spaces, which was not in accordance with facility policy or professional standards. Review of the facility's medication administration policy further supported the requirement for timely and complete documentation on the MAR.