MAR unsigned

ktwlpn, LPN · Nov 24, 2003

Originally posted by nurse62
I work in a LTC facility. The other day, during my 5 PM med pass I noted 4 consecutive unmarked days a med had not been signed off. It was not marked as held, resident refused, JUST SIMPLY BLANK.
The med was in the cart, so I then went to the residents chart to note the most recent lab in which this drug would effect. Well, the drug most positively should of been administered. I called the DR. received new orders and completed the necessary paperwork and then turned the information over to my supervisor.

I really have a problem with this. This has happened too many times, and I have went to the DON twice now concerning this. The first time she gave me a little yellow sticky note to place along side the empty slots "nurse's please sign" with her name signed. Well, when the other nurses seen the sticky note, the ones at fault were pretty upset at me for going to the DON.

The second incident , a resident's lab tests showed the med should of been held and the doctor notified. The lab was faxed, however no reply was documented from the doctor and the med was administerd (for 6 days). Thus I called the doctor and received the new order, notified the family, placed the patient on a 72 hour follow up, and completed the paper work. I informed my DON that it has become part of my practise to always check the level of this drug prior to administering due to the errors I have found and asked for an inservice.

The next inservice we had, the DON stated to us, that if a drug is not administered it must be documented "why" and if not the nurse's license may be on the line "NOTHING GOES COMPLETELY UNSIGNED ON THE MAR!". As well as, "nurses you can not just fax, you have to receive a reply, and it needs to be documented that you notified, received the reply and followed the order.

With this most recent error, an RN said to me "Just restart the drug, if we called the doctor on every med error we wouldn't get anything done!" In which my come back was "Noooo, I am informing the DR. ......and ya know if people would do their job correctly, I would be getting a lot more done right now!" Ya know I have a BIG PROBLEM calling a doctor and stating, "the med hasn't been signed off in four days and the last lab results were such and such, and nothing is documented in the nursing notes....."

Nobody can convince me that I am incorrect about feeling this way. And nobody can convince me that I should just overlook such errors. And yes it does take time to complete all the paperwork involved, and no I don't like other nurses being upset with me. BUT.......there is a person on the other side of all of this and is the patient. If we overlook such errors aren't we overlooking the patient entirely. I am not perfect by no means...and I hope I don't come across that way. Errors happen and I know there are many reasons behind such errors. But four days..........................come on now.

Comadin? Scary to think that some of your co-workers would let that slide and not follow up on obtaining orders.I have a few co-workers that skipped administering a resident's lasix for several days and charted (unavailable) Did NOT look in the emergency box(on each unit and was available there) Did NOT call pharmacy to check on delivery-did not call the doc...I think they really did not consider why the drug is given.The resident was OK but the state dinged us.... We have several new grads and many PRN nurses and they seem to lack critical thinking skills and also seem to let things slie as if they just don't feel responsible.....They seem to have the attitude that the full time charge nurses can handle it all....

elkpark · Nov 24, 2003

My current job (x 3 yrs) is as a surveyor/consultant for the agency in my state that licenses and regulates hospitals. I can assure you that any state or federal surveyor who finds "holes" in an MAR will assume that the med was not given and write that up as a deficiency in the final report. If it is enough of a pattern or appears to put patients in danger, it could actually get the facility in serious trouble. It doesn't really matter if the med was gone from the drawer, if the Pyxis printout shows the med was signed out of the machine, if the pharmacy records show that the patient was charged for the med, if someone is sure the nurse must have given the med, if the nurse TOLD someone that s/he gave the med. The standard is, IF IT WASN'T SIGNED OFF ON THE MAR, IT WASN'T GIVEN.

Although I don't survey LTCs in my state, I do know that our rules for group homes and other types of residential treatment facilities specifically require that the physician be notified of _every_ med error (and that this notification and the physician's response be documented, OF COURSE).

You need to continue to C Y own A, and it might be worth checking on what your specific state rules that govern LTCs require in terms of notification. Good luck!

jschut, BSN, RN · Dec 22, 2003

We have TONS of places in the MAR that are not signed off, and the DON, simply says for us to go ahead and sign them off.....

No questions asked.

Personally, I go through and if I find one unsigned, I like to check as to why. I must be the only one. ANd when I threw a fuss over the DON signing my initials, she got rather gruff and said in a meeting, "For those who think they are too good to have me signing their initials...tough! Somebody has to fill in the MAR, and it's not gonna be my orifice when you guys forget to do it!"

(Yea, she's a real professional!)

I've started making copies of MAR sheets when there are a few places missing.....

I was told the other day, that I should've been a detective cause I am always finding something and documenting on it! LOL!

BRANDY LPN · Dec 22, 2003

Julie-

OMG I would not let her get away with signing my initials! I would report this to the BON, in my state if I didnt i could be disiplined as well. just my .02 worth. :eek:

Trixxy, LPN · Dec 23, 2003

I also work in a LTC facility, and yes signatures on MAR's and TAR's get missed...whether by oversite or by getting sidetracked with interruptions. I miss some myself once in a while. I just leave notes on the MAR/TAR with the nurses name and date the signature was missed. Not as an insult, but just as a reminder to sign it. At first the other nurses were upset about this practice :chair: ...but once they learned that I didn't care whether it pissed them off and that I was going to do it anyway as a friendly reminder, they've come to expect it and sign their missed spots. Now, they love to search for my missed initials so they can leave a sticky note with my name on it, which is totally ok with me..at least I've got them looking. :clown:

Our facility started a new rule... you sign your MAR's/TAR's or you don't get your paycheck until you do...so needless to say, it's not a big problem any longer.

(It personally drives me insane...causes me extra footwork, which I don't appreciate it all. )

It's NOT ok for anyone to sign your initials on ANYTHING! :nono:

As far as missed lab results..you need to figure out a way to ensure that all the steps are being followed through on.

We also fax our results to the MD, but if that doctor hasn't given us orders by 8pm, we call him...whether the order is "NNO" or a change in medication.

Always notify the doctor with a medication error.

Sounds like you are very frustrated...and with reason. Remember though...being a patient advocate is a good thing!

Marti Ann · Dec 23, 2003

Even though this is not the number 1 tag in nursing homes. This comes under Tag 0426: Facility Provides Pharmaceutical Service.In my inspections this is my #1 pet peeve with nurses and the most problems I find. Sorry Nurses, {I am a nice person}.

Nurses take two to three hours to pass meds in most nursing homes, and yes, before you get mad at me, I to was a DON and passed meds at a nursing homes at one time in my life,

but I hear so many different excuses.

I feel bad I have to take that nurse's name, report her to the DON and Adm. and she has to have an inservice about meds, and yes, we refer it to AHCA.

So please each and every time you ck that arm band or ask that PT. or resident's name, go right back to your cart and sign on that MAR, then go to the next resident in that room or next door.

It will take you 2 mins. longer but then it is documented for sure you gave those medsand you practiced safe nursing. Most of the time nurses forget to document the refusal and the action of the pt meds. {ie: relief from pain meds.}

My other pet peeve is not enough or any DOCUMENT in the nurses notes.But that's another story!!!!!

TracyB,RN, RN · Dec 23, 2003

Oh MY God. . .What perfect timing. This is the kind of crap I deal with on a daily basis. I am sooooooooo sick & tired of begging nurses to do their jobs. Can't wait till Jan 5. I am soooo outta there. I refuse to sign anyone's initials, although that seems to be the common practice where I work. I have only been a nurse for 11yrs. I have a loonng time to work & am not gonna risk my license for someone else's laziness.

If I never again have to call a doc & tell him the news that so & so hasn't gotten their blank it will be too soon.

nurse62 · Dec 23, 2003

Yes, the main reason for holes on the MAR is due to being interrupted, which many times can't be helped, at the time. However, before turning over the med cart to another nurse, nurses should always look back thru their days work to make sure they didn't miss signing. It only takes a few minutes, and saves the next nurse a lot of unnecessary worry and work. Just the other day one of the residents c/o not sleeping as well as usually does thus feeling lousy. After I assessed the res I went to the MAR to see if res had anything to assist sleep. I noted scheduled Benadryl at HS but also noted over the last seven days in which the nurses intitials were circled, "med not available". The resident's med come from our in house pharmacy, thus I called them. Due to medicare regulations, the med was ordered too soon, thus they could not send until the next day, or we pay for the med. I advised the DON, which instructed me to pass on in report for the night nurse to take it from the EDK. (By the way I work day shift.) Easy enough to pull from the EDK, two minutes at top. My total time, with assessment, phone calls, speaking with the DON, took at least 15 minutes. Time consuming to say the least, and so dang simple to avoid.

Trixxy, LPN · Dec 23, 2003

You need to file a complaint with the state...it's not ok to not give a med because it's unavailable day after day after day. Stop playing with these people.

Come work at my facility...you'll love it. :)

Nurse Soc Mom · Dec 27, 2003

If the MAR is not signed, it was not done! I personally review all of our facilities MARs on a monthly basis and note who the nurse was on that shift that did not sign the MAR as given or as held and give them a report on how many holes they had for that particular patient and month. It is fraudulent on their part and mine if I were to ask them to sign them days later. (how would they remember?) It does open their eyes and help them improve when they see these things in writing because they actually go back and check for themselves that they did not fill it in. If a MAR is not signed it is a variance and action needs to be taken to correct it. I truly believe most nurses want to do a good job and it is just an oversight with their many other responsibilities.

KaroSnowQueen, RN · Dec 27, 2003

I used to work LTC and gave it up because of this kind of garbage. At the end of the month, there would be holes all over the mars and the adon would say "Fill in the holes". She said put in anybody's initials or scribble something, doesn't matter if you can read it or not.

And they would leave one nurse to give meds to 40 patients. You cannot give meds to 40 persons in a timely fashion, you have those with tubes, those who have to take their 23 pills ONE AT A FLIPPIN' TIME, those who need it crushed in applesauce, etc.

And meds not available from pharmacy. They WOULD NOT send them if ordered too soon, doesn't matter if the patient had been out of them for a week, it was just too bad.

Not to mention one aide for 40 patients on second and third shifts. Then the nurses get reamed because of skin breakdown. No wonder with the penny pinching staffing they give us.

I didn't mind LTC when I had staff and supplies but those days are long gone.