Failure to Document PRN Medication Administration on MAR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to document the administration of a PRN Ipratropium-Albuterol Solution on the Medication Administration Record (MAR) for a resident with a history of pneumonia, urinary tract infection, and acute respiratory failure with hypoxia. The resident, who had documented short-term memory problems and moderately impaired cognitive skills, was admitted and later readmitted to the facility. The physician's order specified the use of Ipratropium-Albuterol Solution via nebulizer as needed for shortness of breath or wheezing. On the morning in question, the LVN administered the medication due to observed chest congestion but did not record this administration on the MAR. During interviews, the LVN acknowledged forgetting to chart the medication administration because of being occupied with other tasks. The Director of Nursing (DON) confirmed that there was no documentation on the MAR for the PRN medication and stated that facility policy requires immediate documentation of all administered medications. Review of the facility's policy further supported that all medication activities must be documented to ensure resident safety and regulatory compliance.