Failure to Document PRN Controlled Medication Administration on MAR
Penalty
Summary
The facility failed to document the administration of medication on the Medication Administration Record (MAR) for one resident reviewed for medication administration. According to the facility's policy, each medication or treatment administered must be promptly documented in the medication record after administration to validate that residents are receiving drugs and biologicals as ordered by the physician. In this case, a resident with diagnoses including a right femur fracture, chronic ulcers on both lower legs, and gait abnormalities was admitted and had a physician's order for Hydromorphone HCl Oral Tablet 4 MG to be given every six hours as needed for pain. Record review showed that the Controlled Drug Receipt/Record/Disposition form documented multiple administrations of Hydromorphone to the resident on various dates and times. Nursing staff confirmed that signing the controlled drug form indicated the medication was administered and that it should also be documented on the MAR. However, review of the MAR for the relevant month revealed that these administrations were not recorded as required, despite confirmation from nursing staff and facility leadership that the medication had been given according to the controlled drug records.