Holes in MARS

[txdon]

I recently accepted a position as an ADON and have the responsibility for auditing MARS/TARS for holes. Our agency has received multiple deficencies in this area. At my previous facility our practice was to have the oncoming nurse check the outgoing MARS for holes. Then I would review and make sure all holes were filled in. If I discovered holes I'd call the nurse responsible and have her come in and fill in the blanks. Our policy was that the nurse only had 24 hours to do this. If that nurse say was with agency sometimes she wouldn't come in. In that case the holes stayed. At this facility managers are filling in the holes. They are telling me they verify with the nurse that the medication was given and fill the holes in. Is this common practice?

[marthyellen]

No. No. No. And you've got to be kidding.

[txdon]

I wish I were. This is what they are doing. How should I handle this? The last manager that objected was let go for "other" reasons. Any suggestions on how to handle this would be greatly appreciated.

[caliotter3]

It is common practice to have the guilty nurse come in and fill in her/his own holes. It is not common practice for the supervisor to do it for them. That is false documentation. I would stop this immediately if I were in your shoes. Sounds as if you are going to have to choose between keeping your job and doing things according to Hoyle. I would start looking for a new job unless you think you can finesse your way around these poor practices.

[txdon]

Do you have any suggestions on how to improve better documentation and prevent this prevelance of holes in the MARS/TARS.

[caliotter3]

I developed my own habit of going over my MARS at the end of my shift. Mostly because the management started a QA practice of having someone go over things with a fine tooth comb and making a list of nurses with mistakes/omissions to fix. From another life, I realized that getting your name on this list on a regular basis with lots of omissions/mistakes would be giving them ammunition to downgrade one during performance eval time. So I policed myself. I would pick someone to do chart reviews, (Med Rcds clerk or shift supervisor or even you), and make up this list and post it at each nursing station. The nurse has to sign off on it when s/he makes the correction. Keep the list as a record, and yes, use this info as input for the yearly performance review.

[Platypus]

At my facility, when we find holes we let the nurse know. We are supposed to be getting them done within 24 hours, but this is not always possible with Baylor weekend and pool nurses. If there is an ongoing issue, they get an education write up. If it continues..they get an actual write up. Three of these and they are fired. Charge nurses, Supervisors and others regularly check the books.

[CapeCodMermaid, RN]

Are there 2 nurses on the floor? Have them swap MARs and check each other's book before they go. You should never sign for something you didn't give/do yourself.

[txdon]

We did that at our last facility and the problem we ran into was overtime and nurses complaining about how much longer it took with shift change. I really like the idea of writing a list of nurses with holes and using it as an evaluation tool for documentation. Thanks for sharing.

[Chin up]

We did that at our last facility and the problem we ran into was overtime and nurses complaining about how much longer it took with shift change. I really like the idea of writing a list of nurses with holes and using it as an evaluation tool for documentation. Thanks for sharing.

You could go the severe route...by that, I mean, say for the next six months. The unit managers, Don, SDC and yourself do daily walking rounds, checking MAR for wholes. As you go through the MAR, one of you records, the room number, med and time med was not given. You do this floor by floor. Then all staff responsible is called immediately to come in that day, to correct their missing entry. You can do a full audit at this time, to make sure PRN's are documented with outcomes, FSBS recorded and proper intervention taken, INR are followed up and flushes, IV written properly. This may take management a hour or two to do daily, but is worth it when staff becomes more diligent with these duties.

Or you can at the end of the month, leave the MAR in the med room, with a command, that nurses check for holes and fill them with in a few days. Those wholes not filled will be treated as not given and a medical error write up will follow.

Another thing you can do, is have the unit managers responsible for their own unit. Since unit managers are so busy, you will see a change in a hurry. They won't want to be responsible for this and will stay on their staff until it becomes second nature.

As for agency, they should go back immediately, or just don't call them back. Good agencies demand their nurses go in right away.

The first instance is a lot of work, but it works. Staff will respond to management going through their books daily and will start doing, what they should have been doing all along. Peace!

Hope this helps.

*edit- just wanted to add, narcotic book should be checked weekly or monthly too. Because even though count may say correct, a number of things could be going on and you can also find missed narcotics this way. Or even cross outs and date changes. We would check narcotic book naturally, if a hole was found where a narcotic should have been given. This way, you will know for sure, if it is just a hole, or was a missed med.