F0755

E

Late Documentation of Insulin Administration on MAR

Reseda, California Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the failure of a registered nurse to document insulin administration on the Medication Administration Record (MAR) immediately after giving the medication. The resident involved was admitted with diagnoses including cerebral infarction, diabetes mellitus, and hypertension, and had intact cognition, was independent with eating and oral hygiene, and required moderate assistance with some activities of daily living. The resident had an order for insulin lispro to be administered subcutaneously per sliding scale before meals and at bedtime for diabetes management. Review of the MAR for the month showed multiple instances where insulin lispro doses scheduled for specific times were documented as administered significantly later than the scheduled times.

During interviews and concurrent record reviews, the RN who documented the insulin administrations stated that insulin was actually given at the scheduled times but that documentation was completed late. The RN explained that blood sugar was typically checked about 30 minutes before dinner and insulin lispro was administered right before the resident ate, but the MAR entries were made after the fact rather than immediately following administration. The DON confirmed that licensed nurses are expected to document medication administration right after giving all medications. The facility’s medication administration policy specified that medications are to be administered within 60 minutes of the scheduled time, except for before- or after-meal orders, and that the person administering the medication must record the administration on the MAR directly after the medication is given and review the MAR at the end of each pass to ensure doses were administered and documented.