Failure to Timely Document Medication Administration in MAR
Penalty
Summary
The facility failed to ensure that clinical records accurately reflected the timing of medication administration for four residents reviewed. In each case, medications were administered according to physician orders, but documentation in the Medication Administration Record (MAR) was completed significantly after the actual administration time. This pattern was identified through an internal medication administration audit, which flagged late documentation for medications scheduled primarily around 9:00 A.M., with entries often made between 10:00 A.M. and 2:00 P.M. This issue affected approximately 80 residents across various units. For the residents involved, all had significant medical conditions such as dementia, failure to thrive, hypertension, diabetes, and behavioral disturbances. The MARs for these residents showed that medications, including supplements, psychotropics, and other daily treatments, were documented as being administered hours after the scheduled time. Interviews with nursing staff revealed that the delay in documentation was due to workload and the practice of signing off on the MAR after completing medication rounds for all assigned residents, rather than at the time of administration. Facility leadership, including the DON and regional nurse, confirmed that their expectation was for medications to be documented in the MAR at the time they are administered. The facility's own policy also required immediate documentation following administration. Despite the delayed documentation, there were no reports of negative outcomes or missed doses for the residents involved, as confirmed by the medical director and facility incident summaries.