Inaccurate MAR Documentation and Failure to Document Antibiotic Refusal
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for a resident in accordance with professional standards. The resident was admitted with multiple diagnoses, including UTI, vascular dementia, protein-calorie malnutrition, pneumonia, and anxiety disorder, and had physician orders for several medications, including sertraline, Colace, cranberry tablets, memantine, Liquacel, acetaminophen, and later amoxicillin-potassium clavulanate for pneumonia. The facility’s policies required that documentation in the medical record be objective, complete, and accurate, and that medication refusals be documented with physician notification, particularly for antibiotics. On the date in question, the Medication Administration Record (MAR) showed that the resident received seven ordered medications, including the antibiotic amoxicillin-potassium clavulanate, at a morning administration time. However, the assigned LVN reported that the resident was not eating breakfast and would not open his mouth, and therefore the morning medications were not actually given. Despite this, the LVN signed off all seven medications on the MAR as if they had been administered and did not enter any note indicating that the medications were signed off in error or that they were refused or not taken. During interviews, the LVN acknowledged that the medications were not given, that she had signed them as administered by accident, and that she did not complete the required corrections on the MAR to indicate wrong documentation. She also stated she did not notify the physician at the time the antibiotic was refused and only informed her supervisor several hours later when the resident also refused lunch. The DON confirmed that if a resident refuses or is unable to take medications, the nurse should not sign them as given, should document the refusal and the reason, and should notify the MD within the shift for missed or refused antibiotics. The DON characterized the MAR entries as inaccurate documentation and noted that the facility’s policies required accurate charting and same-day physician notification for refusal of antibiotics.
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