Failure to Accurately Document Medication Administration on MAR
Penalty
Summary
The facility failed to accurately document the administration of medications on the Medication Administration Record (MAR) for a resident with multiple complex diagnoses, including pneumonia, multidrug-resistant infections, quadriplegia, and dementia. Physician orders required the administration of Cefiderocol intravenously every 8 hours for a specified period. Review of the MAR revealed blank entries for scheduled doses on two occasions and an unexplained 'X' for another scheduled dose, with no documentation in the medical record to indicate whether the medication was administered, the reason for non-administration, or if the physician was notified. Interviews with facility staff confirmed that the antibiotic was present in the facility at the time of the missed dose, but there was no progress note or documentation explaining the missed or undocumented doses. Staff acknowledged that on at least one occasion, the medication was not administered because it had not yet arrived, and the physician was reportedly contacted, but this was not documented. On other occasions, nurses admitted to forgetting to document the administration of the medication after it was given. The facility's policy requires immediate documentation of medication administration, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.