Medication administration must be performed only after verifying the resident, medication, dose, route, time, indication, allergies, relevant vital signs, lab results, hold parameters, and provider orders. Nurses must compare the order, MAR/TAR, pharmacy label, and resident-specific instructions before administration.
MAR/TAR documentation must be completed accurately and timely. Do not document before administration. If a medication or treatment is refused, held, unavailable, omitted, delayed, or not given, document the reason, assessment, nursing action, notification, and follow-up monitoring. CMS guidance states that facilities must ensure medication error rates are not 5% or greater and that residents are free from significant medication errors.
Nurse Responsibilities
- Verify orders before administration.
- Follow facility policy for medication pass, treatment pass, crushing medications, G-tube medication administration, and insulin administration.
- Monitor for therapeutic effect and adverse reaction.
- Report and document medication errors immediately.
- Notify provider, supervisor, pharmacy, resident representative, and DON/designee as required by policy.
Competency
Medication pass observation and MAR/TAR documentation audit.