False MAR Documentation After Medications Left Unadministered at Bedside
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one resident when an LVN signed the Medication Administration Record (MAR) indicating medications were given, although they were not administered. The resident, who had diagnoses including essential primary hypertension, unspecified atrial fibrillation, and anemia, was care planned as requiring supervision with toilet hygiene and bathing, and being independent with eating and oral hygiene. The resident’s February MAR showed that on 2/11/2026 at 9:00 a.m., multiple medications were scheduled, including chlorthalidone 50 mg (½ tablet) for CHF, ferrous sulfate 325 mg, memantine HCL 5 mg, a multivitamin, docusate sodium 100 mg, and hydrochlorothiazide 50 mg. The MAR for that date indicated that chlorthalidone, ferrous sulfate, memantine, docusate sodium, and hydrochlorothiazide were documented as administered at 9:55 a.m. However, surveyor observations on 2/11/2026 showed that at 9:45 a.m. LVN 1 entered the resident’s room with a medication cup and then left the room, and at 10:00 a.m. and again at 11:29 a.m. the same medication cup with six pills remained on the bedside table, indicating the medications had not been taken. In an interview, LVN 1 stated she had placed the medication cup with pills on the bedside table and left because she was called to assist another resident, acknowledged it was not her usual practice to leave medications unattended, and admitted she should not have signed the MAR indicating the resident received the medications when they had not been administered. The DON confirmed that the correct process is “pour-pass-chart,” and that signing the MAR before administering medications constitutes false documentation. The facility’s medication administration policy stated that missed medications should be flagged on the MAR and documented immediately after administration by the person who gives the dose.
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