Failure to Accurately Document Medication Administration on MAR
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral infarction, chronic right heart failure, hypertension, and peripheral vascular disease, did not receive their prescribed Metoprolol 100 mg twice daily for hypertension. The medication was unavailable beginning on 05/24/25, and the LPN reported issues with reordering the medication from the pharmacy, including the need to discontinue and rewrite the order so it would be recognized by the pharmacy system. The LPN also stated that the contingency box did not contain the correct dosage, and the medication had not arrived despite follow-up calls to the pharmacy. Despite the medication not being administered, the LPN documented on the medication administration record (MAR) that the Metoprolol was given on several dates. There was no evidence in the resident's progress notes that the medication was unavailable or not administered. The facility's policy required appropriate documentation if a drug was withheld, refused, or given at a different time, but this was not followed, resulting in inaccurate documentation of medication administration.