Can an Administrator Write Orders in an MAR?

An RN said an administrator at an assisted living facility — who isn’t a nurse — wrote an order in a resident’s Medication Administration Record (MAR). The nurse is wondering if this is legal.

According to the organization Healthcare Administration, assisted living facility administrators “manage and supervise healthcare services for older people who need regular care with daily tasks.” They also manage staff, oversee employee training, and develop schedules for staff. However, they don’t provide direct patient care.

Assisted living facility administrators who are licensed nurses may occasionally be involved in some aspect of patient care, such as helping a patient get dressed, when they’re short on staff, but they aren’t involved in the day-to-day aspects of residents’ medical or nursing care.

As you know, the MAR is a legal document that reflects any and all medications administered to a patient or resident. A nurse or another healthcare provider who administers a medication must sign off on the MAR as having given the medication. The medications listed on the MAR should reflect the drugs ordered by an authorized healthcare provider, such as a licensed physician or a licensed advanced practice nurse (APRN).

The RN didn’t say what type of order she was asking about, so it’s difficult to respond completely to her question, but this scenario raises many questions about the legalities.

Concerns about the MAR

Although the RN stated that the administrator wasn’t a nurse, we don’t know if the administrator is another type of licensed healthcare provider, such as a physician.

Licensed healthcare providers who aren’t directly involved in a resident’s care should not be in the habit of ordering medications. However, the state issued a license to this facility, and the RN needs to know the stipulations of that license — and any other rules that could apply to this situation, so she can determine how to proceed. For example, a physician administrator may have written an order in an emergent situation. Although this isn’t part of the administrator’s responsibilities, this seemingly inappropriate action may be mitigated by special circumstances.

Even so, this raises the question of what took place after the order was written. Did they notify the resident’s family and primary care physician? Did they document the notifications in the resident’s medical record?

If it wasn’t an emergent situation, why was the order written? Was it based on the resident’s medical condition? Was it for some kind of fraudulent reimbursement for medications? Another disconcerting notion is that the facility administrator might be ordering the medication for someone other than the resident.

Which raises another concern: How did the administrator sign the MAR? Did they use their own signature and initials? Or did they use a nurse’s signature and initials? If it was the latter, then falsification of the documentation occurred.

Another major concern for the nursing staff is they may be administering medication based on an order that wasn’t issued by an authorized, licensed healthcare provider. This could result in professional disciplinary action by the state board of nursing, if the nursing staff knew the order wasn’t consistent with the state’s requirements, but they carried out the order anyway. Charges such as unprofessional conduct and a breach of standards of practice could be levied against nursing staff members.

In addition, the question arises as to how many times the facility administrator wrote orders in residents’ MAR records. Was it just one time and for one resident?

Last, but certainly not least, is the impact of the facility administrator’s actions upon the residents’ care. Are those residents being charged for medications that aren’t being used in their treatment? Are they getting the medications they need? If a resident needs to be hospitalized, will their MAR accurately reflect the medications they’re receiving?

How to protect yourself and your practice

It’s unclear if these legal and ethical issues are a reality because so little information was supplied by the RN. Even so, it’s clear that the RN should seek counsel from a nurse attorney or attorney who can help sort out the specifics of the administrator’s actions and counsel the RN as to the course of action they should take.

At a minimum, if the attorney decides the conduct is not within the administrator’s obligations and is concerned about illegal conduct, the RN may be counseled to notify a state regulatory agency that oversees assisted living facility administrators.

Whatever the outcome, a nurse has the obligation, both legally and ethically, to report conduct that is illegal, threatens patient safety, or otherwise violates the law.

Doing so with sound legal representation is the best approach to any questionable conduct that a nurse becomes aware of and which threatens patient care and their license.

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