Assisted living survey tip—Documentation of administration of medication
By Michaun Shetler | January 31, 2025 | Assisted living providers
Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. The documentation must include the medication name, dosage, date, and time administered, and method and route of administration. The staff must document the reason medication administration was not completed as prescribed and document any follow-up procedures that were provided to meet the resident's needs when medication was not administered as prescribed and in compliance with the resident's medication management plan.
Below are a few survey findings:
- When staff administered MiraLAX® they did not use the cap which is designed to equal seventeen grams, a typical amount prescribed by physicians; instead, staff used spoons or other measuring tools causing the improper dose to be given. In most cases, less than prescribed
- Staff administer a pro re nata (PRN) medication to a resident without the resident requesting the medication; staff indicated that they noticed the resident was short of breath, so they administered a PRN inhaler instead of discussing it with the resident
- Unlicensed personnel (ULP) signed off a monthly injection that was given by a licensed professional, although the licensed professional gave the injection; this was standard practice
- Medication prescribed but not available for administration; lacked documentation and/or follow up documentation
- Documented the administration of medications but did not observe the process or left resident with medication to consume on own; policy indicates to observe resident take medication
- A resident was not given scheduled medication as ordered; staff reported they did not administer because the resident was up all night
Proper documentation is essential for ensuring the safety and well-being of residents, as well as for compliance with regulatory standards. Ensure that all staff responsible for medication administration are trained. If the lack of documentation is linked to staff not following procedures, retraining may be required. If the error is due to a specific staff member’s actions or lack of knowledge, consider addressing the issue through a performance review or further education on proper documentation practices.
Conducting routine internal audits or random checks of MARs and following staff during medication passes can help improve quality, allow for just in time training and immediate correction. Look for process improvements, and review policies and procedures.
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Michaun Shetler | Vice President of Regulatory Affairs |
mshetler@careproviders.org | 952-851-2484