Medication Administration Documentation Deficiency
Penalty
Summary
A deficiency occurred when a resident did not receive medication as ordered, and the facility failed to ensure accurate documentation on the Medication Administration Record (MAR). Specifically, the MAR for October showed a blank entry for the administration of Diclofenac Sodium External Gel 1% for pain, with no documentation indicating whether the medication was given or the reason for omission. Review of the nurse's progress notes for the same date revealed no explanation for the missing documentation. The resident involved was an adult male with multiple diagnoses, including anemia, heart failure, hyperlipidemia, hemiplegia/hemiparesis, depression, malnutrition, morbid obesity, chronic diastolic heart failure, and osteoarthritis. His initial Minimum Data Set (MDS) indicated intact cognitive skills for decision-making and varying levels of assistance required for daily activities. At the time of observation, the resident was alert, oriented, and able to communicate his needs, and he reported receiving pain medication when requested. Interviews with nursing staff confirmed that there should be no blanks on the MARs or Treatment Administration Records (TARs), and that any medication not administered should be documented with a reason. The facility's policy also required staff to document administration or reasons for omission. The lack of documentation made it unclear whether the medication was administered as ordered, constituting a medication error and a failure to meet pharmaceutical service requirements.