| 6400.166(a)(11) | The medication administration record for November 2021 for Individual #1 does not list the reason or diagnosis for the prescribed Deep Sea Spray, Fluticasone, One-A-Day Chewable, Montelukast, and Pantoprazole. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | During the inspection, we presented information regarding our progress in preparing to use ChartMeds as an electronic MAR system. In ChartMeds, the diagnosis for each medication has been entered and will appear on the electronic MAR for each medication for each administration. We will begin piloting ChartMeds in February and institute ChartMeds across our department in April 2022. Until that time, we do have documentation that provides the diagnosis/reason each medication is taken for that is kept in the medication binder with the paper MARs. This has always been our practice, unfortunately we did not present this during the inspection process. |
01/12/2022
| Implemented |