Failure to Accurately Document Behavioral Episodes in MAR
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Medication Administration Record (MAR) for a resident with dementia and hypertension. The resident, who had severely impaired cognitive skills and required maximal assistance with daily activities, was prescribed Seroquel for psychosis and agitation. Physician orders required monitoring and documentation of episodes of psychosis, agitation, or aggression every shift. On a specific date, a Licensed Vocational Nurse (LVN) completed an SBAR Communication Form indicating an episode of physical aggression but documented in the MAR that there were no such episodes during the same shift. During interviews and record reviews, the LVN acknowledged the documentation error, stating that the MAR should have reflected the episode of aggression. The Assistant Director of Nursing (ADON) confirmed that licensed nurses are expected to accurately document behavioral episodes in the MAR for residents on psychotropic medications, as per facility policy. The facility's policy emphasized that medical records should be objective, complete, and accurate to facilitate communication among the care team.