Incomplete Medication Administration Record Documentation
Penalty
Summary
A deficiency was identified when a resident's Medication Administration Record (MAR) for July 2025 contained blank spaces on July 5, 2025, instead of the required documentation for medication administration and monitoring. The resident, who had diagnoses including essential primary hypertension, generalized anxiety disorder, and type 2 diabetes mellitus, was prescribed multiple medications and required regular monitoring as outlined in their care plan and physician orders. Review of the MAR showed that documentation was missing for the administration of antihypertensive and antianxiety medications, pain assessment, and blood glucose checks on the specified date. Additionally, there were no progress notes for that day regarding medication administration. Interviews with facility staff confirmed that the nurse assigned to the resident on the date in question did not document the administration or refusal of medications and monitoring. The Director of Nursing acknowledged the blank spaces and stated that it was expected for nursing staff to document all medication administration or refusals. The facility's policy required complete, accurate, and timely documentation in each resident's medical record, which was not followed in this instance.