Failure to Reference MAR During Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) prepared and administered medications to a resident without referencing the Medication Administration Record (MAR), as required by facility policy and professional standards. During the medication pass, the LPN relied on memory and the Twenty-Four-Hour Report for new or changed physician orders, rather than verifying the physician's orders and the five rights of medication administration against the MAR. The laptop on the medication cart displayed only the resident roster, not the individual MAR, during the preparation and administration of medications. The resident involved had a history of Type 2 Diabetes Mellitus and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The resident had active physician's orders for Warfarin Sodium and Oxycodone/Acetaminophen. The LPN documented the administration of these medications in the electronic MAR, but did not reference the MAR during the actual medication pass, contrary to facility policy and training requirements. Interviews with the Staff Development Coordinator and Director of Nursing confirmed that referencing the MAR is a required step in the medication administration process.