Incomplete and Inaccurate Medication Documentation on MARs and Nurse's Notes
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in documentation errors on Medication Administration Records (MARs) and nurse's notes. For one resident with atrial flutter and hypertension, physician orders required that Metoprolol and Digoxin be held if certain blood pressure or heart rate parameters were not met. However, on specific dates, the MARs showed that these medications were not given, but there was no documentation of the resident's blood pressure or heart rate, and the relevant sections on the MARs were left blank. Staff interviews confirmed that there should be no blanks on the MARs, as this makes it unclear whether medications were administered or withheld. For another resident with hypertension, physician orders specified that Metoprolol should be held if systolic blood pressure was below a certain threshold. The MARs indicated that the medication was administered on days when the resident's blood pressure was below the hold parameter, but there was no documentation in the nurse's notes explaining why the medication was given despite the low blood pressure. The staff member responsible for administering the medication stated that the documentation was an error and that the medication was likely held, but she had forgotten to document it correctly. Facility policy required that all entries in medical records be complete, legible, and made in chronological order without leaving blank spaces. Interviews with staff and the Assistant Director of Nursing confirmed that the expectation was for all medication administration and reasons for holding or giving medications to be clearly documented in the clinical records, and that blanks on the MARs were not acceptable.