Inaccurate MAR Documentation for Blood Draw Orders
Penalty
Summary
The facility failed to ensure the accuracy of the Medication Administration Record (MAR) for a resident with diagnoses including myelodysplastic syndromes, anemia, and diabetes. The MAR showed that a scheduled CBC blood draw was documented as completed twice a week, on both Wednesdays and Thursdays, instead of the ordered frequency of once a week. The laboratory reports, however, confirmed that the blood draws were only performed once weekly. This discrepancy was due to the presence of two active orders in the MAR—one for Thursdays and another for Wednesdays—without discontinuing the earlier order when the new one was entered. Staff interviews revealed that nurses and medication aides marked the MAR as completed based on the assumption that the task was done, with one aide admitting to marking the MAR in error. The phlebotomist clarified that the blood draws were changed from Thursdays to Wednesdays in March, but the MAR was not updated accordingly. The DON acknowledged that the previous order should have been discontinued when the new order was implemented, and the administrator confirmed that tasks should only be marked as completed when actually performed.