Maintaining Records on Medication Assistance

How HFRD classifies it

HFRD prints a scope-and-severity letter beside each citation, on the grid the federal nursing home survey uses: A to C is a deficiency with no actual harm and the potential for minimal harm, D to F no actual harm with the potential for more than minimal harm, G to I actual harm that is not immediate jeopardy, and J to L immediate jeopardy; within each band the letter rises from isolated to pattern to widespread. D is by far the most common.

Where it is cited

What the requirement says

HFRD’s requirement text as it appears on the inspection report, verbatim.

111-8-63-.20(9) Maintaining Records on Medication Assistance and Administration. Where the assisted living community either provides assistance with, or supervision of self-administered medications or administers medications to residents, the community must maintain a daily Medication Assistance Record (MAR) for each resident who receives assistance or administration. The MAR must include the name of the specific resident, any known allergies, the name and telephone number of the resident's health care provider, the name, strength and specific directions including key side effects and adverse reactions for use of each medication and a chart for staff who provide assistance or administration to record initials, time and date when medications are taken, refused or a medication error is identified (e.g. missed dosage). The staff providing the assistance or administration of medications must update the MAR each time the medication is offered or taken.