Failure to Document Vital Signs in MAR for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain complete and accurate clinical medical records for one resident, specifically by not documenting vital signs in the Medication Administration Record (MAR) over a period of several weeks. The resident in question was an elderly female with multiple diagnoses, including Type 2 diabetes, dementia, high blood pressure, coronary artery disease, and acute kidney failure. Her care plan required monitoring and documentation of blood pressure due to her condition and prescribed medications, including Midodrine, which was to be held if systolic blood pressure was 130 or above. Record review showed that vital signs were not documented in the MAR from 10/01/25 to 10/24/25, despite physician orders and care plan interventions requiring this information. Interviews with medication aides and the Director of Nursing confirmed that there were issues with the documentation system and that staff were aware of the importance of accurate and timely documentation of vital signs. The facility's own policy required factual, complete, and timely documentation in the medical record, which was not followed in this instance.