Inaccurate MAR Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for one resident when the Medication Administration Record (MAR) incorrectly indicated that a prescribed dose of Ceflozane Sulfate Tazobactram Sodium (CSTS) was not administered because the resident was hospitalized. A review of the resident's transfer form showed that the resident was not transferred to the hospital until 7:15 p.m., but the MAR entry at 4:00 p.m. on the same day stated the medication was withheld due to hospitalization. The Director of Nursing (DON) confirmed that the resident was still present in the facility at the time the medication should have been administered and that the MAR entry was inaccurate. Facility policy titled 'Completion and Correction' requires that all entries in the medical record be complete, legible, and accurate. The DON acknowledged that the MAR entry did not meet these standards, as it did not accurately reflect the resident's status or the administration of the prescribed medication. This resulted in an inaccurate medical record for the resident.