Inaccurate MAR Documentation for Bedtime Medications
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure accurate documentation of medication administration for one resident. The facility’s medication administration policy required licensed nurses to administer medications as ordered, sign the MAR after administration, and document refusals. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, heart disease, bipolar disorder, and pain disorder, was ordered multiple sedating and pain medications, including scheduled lorazepam at bedtime, acetaminophen and gabapentin three times daily, and PRN morphine. On the night in question, the resident became lethargic, diaphoretic, minimally responsive to sternal rub, non-verbal, and unable to keep their eyes open, prompting staff to call 911 and send the resident to the ER. Documentation sent with the resident to the ER, specifically the MAR, indicated that the resident’s bedtime medications had been administered, but subsequent review and interviews revealed they had not been given. The ADON reported receiving conflicting accounts about whether the HS medications were administered and later located the HS medications still in the medication cart, while confirming that the MAR sent to the ER showed them as given. The RN on duty admitted that she documented the HS medications as administered on the MAR before attempting to give them and that, when she went to administer them, the resident was sweaty and refused the medications. The DON and ADON both confirmed that staff should not document medications as administered prior to actually administering them and that nursing staff were expected to follow the facility’s medication administration policy.
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