Medication Administration

Staff responsibilities, MAR accuracy, documentation expectations, medication error response, and safe storage practices for Colorado HCBS providers.

Staff Responsibilities

• Complete agency-required medication administration training and competency checks before administering medications
• Follow all physician orders exactly as written — never alter doses, timing, or routes without a new order
• Verify the five rights before every administration: right person, right medication, right dose, right route, right time
• Document medication administration in the MAR immediately after — never before or hours later
• Observe the individual during and after administration for adverse reactions
• Report medication refusals, errors, or reactions to your supervisor immediately
• Maintain confidentiality about all medication information
• Never administer a medication you have not been trained and authorized to administer

Medication Documentation

Record immediately after administration: 

Document the date, time, medication name, dose, route, and your initials in the MAR right after the individual takes the medication.

Document refusals clearly: 

If an individual refuses medication, record the refusal with the date, time, reason given if stated, and the name of the supervisor notified.

Record holds and discontinued orders: 

If a physician holds or discontinues a medication, document the order date, who communicated it, and when the change took effect.

Never leave a blank: 

A blank MAR entry implies the medication was not given and not explained. Use the appropriate code (administered, refused, held, not available) for every scheduled dose.

Corrections: If you make an error in the MAR, draw a single line through it, write 'error,' initial, date, and make the correct entry. Never white out or backdate.

MAR Accuracy

Monthly MAR Review: 

Supervisors should review completed MARs monthly to identify patterns — repeated refusals, missed doses, or documentation gaps.

Weekly Spot Checks: 

Supervisors should conduct weekly spot checks of active MARs to catch and correct errors before month end.

Competency Checks: 

Staff should be observed administering medications and documenting the MAR at hire and on a regular schedule thereafter.

Physician Order Alignment: 

At the start of each new MAR period, verify that all entries align with current, valid physician orders.

Medication Errors

A medication error is any deviation from a physician's medication order, including administration of the wrong medication, wrong dose, wrong route, wrong time, or medication given to the wrong person.

Step 1 — Assess the individual: Check for any immediate adverse reactions or symptoms. Call 911 if there is any sign of a medical emergency.

Step 2 — Notify your supervisor immediately: Do not wait. Notify your supervisor regardless of whether the error seems minor.

Step 3 — Contact the physician or pharmacist: Your supervisor or the physician should be consulted about any clinical implications and follow-up monitoring.

Step 4 — Document thoroughly: Complete an incident report. Record the error factually — what was ordered, what was given, the time, the individual's condition, and every action taken.

Step 5 — Notify family/guardian: As required by the support plan and agency policy, authorized family members or guardians should be notified.

⚠ Important: Repeated medication errors, or failure to report a known error, can result in corrective action, suspension of an employee's authorization to administer medications, and survey findings for the agency.

Storage and Security

• Store all medications in a locked, secure location — accessible only to authorized staff
• Keep medications in their original, labeled containers — never mix medications or transfer to unlabeled containers
• Store medications at the temperature specified on the label (room temperature, refrigerated, or protected from light)
• Maintain a current medication inventory and reconcile it regularly
• Dispose of expired or discontinued medications per agency policy and applicable state disposal rules
• Controlled substances require a separate log and must be counted at each shift change

Observation and Reporting

After administering medications, observe the individual for side effects, adverse reactions, or changes in condition. Report the following to your supervisor:

• Signs of allergic reaction — rash, hives, swelling, difficulty breathing
• Nausea, vomiting, or stomach pain occurring after administration
• Dizziness, confusion, or unusual drowsiness
• Changes in behavior, mood, or alertness that appear medication-related
• Repeated refusals of a specific medication
• Any complaint from the individual about a medication

Need Help? Contact Extended Care Services Education

Extended Care Services Education offers consulting, staff training, mock audits, and compliance support tailored for Colorado HCBS providers.

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