Failure to Provide Accurate MAR Documentation for Tube Feeding Schedule
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's tube feeding schedule on the Medication Administration Report (MAR). Review of the clinical records for a resident with multiple complex medical diagnoses, including severe protein calorie malnutrition, adult failure to thrive, Wernicke's encephalopathy, dysphagia, and achalasia of the cardia, revealed physician orders for enteral feedings at specific times throughout the day. However, the MAR only provided options for staff to document the tube feedings being set up and taken down during the day and evening shifts, with no option for the afternoon. This omission resulted in the inability of staff to properly document the administration of tube feedings according to the prescribed schedule. A registered nurse confirmed that the MAR was not set up to allow for proper documentation of the resident's tube feeding schedule.