Inaccurate MAR Documentation for Fall Prevention Intervention
Penalty
Summary
The facility failed to accurately complete the Medication Administration Record (MAR) for one resident with multiple diagnoses, including cerebral infarction, Alzheimer's disease, dementia with behaviors, diabetes, osteoarthritis, chronic pain, dysphagia, and muscle weakness. Physician's orders and the resident's care plan required bilateral fall mats to be checked and in place at the bedside every shift as a fall prevention intervention. The MARs for several months were signed by nursing staff, indicating that the fall mats were in place for all day and night shifts. However, direct observations on multiple occasions revealed that the resident did not have fall mats present at the bedside. Interviews with environmental services staff and a CNA confirmed that they had not observed fall mats in the resident's room during their shifts. An LPN admitted to signing the MARs as if the fall mats were in place but could not recall seeing them, and the DON confirmed the absence of the fall mats. This demonstrates that the facility did not maintain accurate and factual documentation in the resident's medical record, as required by facility policy and professional standards.