Failure to Maintain Accurate and Complete MAR Documentation for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with professional standards, specifically related to a resident with Type 2 Diabetes Mellitus and other serious diagnoses. Surveyors reviewed this resident’s December Medication Administration Record (MAR) and Order Summary Report (OSR) and found no provider orders for glucagon, despite the DON’s statement that an LPN had administered glucagon three times over two days for hypoglycemic events. The DON acknowledged that the LPN gave glucagon without a provider order, describing the situation as emergent, and further admitted that the LPN did not subsequently contact the provider or have an order transcribed into the record, contrary to facility policy requiring verbal orders to be recorded immediately in the resident’s chart. The survey also identified inaccurate MAR documentation when the DON entered medication administration information on behalf of the LPN. The DON stated that the LPN had reported the resident refused insulin on two dates, and because the LPN was remote and did not have access to the MAR, the DON entered the information using her own electronic signature instead of the LPN’s. This practice conflicted with the facility’s charting and documentation policy, which states that entries in the clinical record must be made by the licensed personnel providing the care, in accordance with state law and facility policy. The LPN did not return the surveyor’s call for an interview, and the DON reported that the LPN declined to speak with the surveyor.
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