Failure to Accurately Document Medication Administration on MARs
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication administration records (MARs) accurately reflected medications administered for four residents. For Resident B, who had diagnoses including a history of deep vein thrombosis and neuropathy, review of the January 2026 MAR showed missing documentation for ordered Eliquis 5 mg doses scheduled in the evening on multiple dates, as well as missing documentation for Gabapentin 600 mg at 10:00 p.m. on the same dates. An LPN stated that when a medication is administered, it should be signed off on the MAR by the nurse. For Resident C, with diagnoses including hyperlipidemia and chronic pain syndrome, the January 2026 MAR lacked documentation of Atorvastatin 40 mg at bedtime and evening doses of Pregabalin 50 mg on several dates. Resident D, diagnosed with insomnia, depression, hyperlipidemia, nerve pain, chronic pain, and muscle spasms, had missing MAR documentation for Aripiprazole, Atorvastatin, Gabapentin, Methocarbamol, and Pregabalin at various scheduled times and dates. Resident E, with diagnoses including hyperlipidemia, myocardial infarction, insomnia, hypertension, depression, and enlarged prostate, had missing documentation on the January 2026 MAR for Atorvastatin, Eliquis, Melatonin, Metoprolol tartrate, Mirtazapine, and Tamsulosin on multiple evenings. The facility’s policy on medication administration required that medication administration be documented when medications are given on appropriate forms, but the MARs did not contain this documentation for the identified dates and times.
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