Inaccurate MAR Documentation for Insulin Administration
Penalty
Summary
The facility failed to maintain accurate Medication Administration Records (MARs) for several residents receiving insulin, resulting in documentation that incorrectly identified Medication Aide (MA) #2 as the individual administering insulin. According to the report, MA #2 was not permitted to administer insulin as it was outside her scope of practice. However, the MARs for three residents with diabetes showed that insulin doses were signed out under MA #2’s name, even though licensed nursing staff actually administered the medication. This practice was confirmed through interviews with both the MA and supervising nurses, who stated that the MA would sign out the insulin after witnessing the nurse administer it, or that the electronic MAR system would prompt the MA to complete the documentation after entering blood sugar values. For one resident with moderate cognitive impairment and physician orders for both scheduled and sliding scale insulin, the MAR reflected multiple instances where insulin administration was signed out by MA #2. Interviews with the resident, MA #2, and supervising nurses confirmed that the MA did not administer the insulin, but signed for it after the nurse gave the injection. Similar documentation discrepancies were found for two other residents with diabetes, one of whom was cognitively intact and confirmed that only nurses administered his insulin. In these cases, the MARs again showed MA #2 as the person administering insulin, despite her not being authorized or actually performing the task. Staff interviews, including those with the Director of Nursing and a unit manager, confirmed that Medication Aides were not allowed to administer insulin and that a supervising nurse was always responsible for giving insulin to residents. The documentation errors occurred because the MA, while entering blood sugar readings or witnessing the administration, would sign out the insulin on the MAR, or the electronic system would default to the MA’s initials. This resulted in inaccurate medical records that did not reflect the actual provider of care, affecting at least three residents whose records were reviewed.