Inaccurate MAR Documentation for Parameter-Dependent Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate documentation on the Medication Administration Record (MAR) for a resident receiving midodrine for hypotension. The physician’s order dated 11/6/25 directed that midodrine 2.5 mg be given twice daily and held if the systolic blood pressure (SBP) was over 120 mm/Hg or the diastolic blood pressure was over 80 mm/Hg. The MAR for November, December, and January reflected this order, yet multiple entries showed blood pressure readings above the ordered SBP parameter with the medication still documented as administered. Specific examples included blood pressures of 124/53, 129/54, 132/60, 122/61, 124/62, 134/68, 126/66, and 127/70 mm/Hg, all recorded with midodrine signed out as given. During interviews, the nursing staff and medication aide involved acknowledged that their documentation on the electronic MAR was incorrect. One nurse stated that on 11/15/25 she documented that she administered midodrine when she had not. Another nurse reported that when the resident’s blood pressure was outside the ordered parameters, he held the medication but erroneously documented it as administered on several dates. The medication aide similarly stated that she documented in error that she administered midodrine on two January administrations. The DON stated that her expectation was that medications be administered and documented accurately, and that when a medication is held it should be documented as held with the reason, and acknowledged that the resident’s midodrine was not documented accurately, emphasizing the importance of accurate documentation for evaluation of the resident’s medical condition.
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