What must be documented when a resident refuses medication?

When a resident refuses medication, it is crucial to document the refusal on both the Medication Administration Record (MAR) and any other forms as dictated by facility policy. This comprehensive documentation is essential for several reasons.

Firstly, the MAR serves as the primary record for medication administration and must reflect any instances where medication was not administered along with the reason. This ensures that accurate records are maintained for tracking medication usage and adherence.

Moreover, documenting the refusal on additional forms may include incident reports or progress notes, depending on the facility's established protocols. This broader documentation helps ensure that all relevant healthcare team members are aware of the refusal and can monitor the resident’s health status and potential repercussions of not taking the medication.

By following these guidelines, the nursing staff can provide consistent and safe care while ensuring that all aspects of the resident's medication management are clearly communicated and logged, thus reducing the risk of errors or misunderstandings.