Inaccurate MAR Documentation for Laxative Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation of medication administration in accordance with professional standards for one resident. The resident had an admission date of 09/09/25 and diagnoses including chronic kidney disease, reduced mobility, and lumbar intervertebral disc displacement. A care plan initiated on 09/10/25 identified the resident as being at risk for gastrointestinal complications due to constipation, with interventions including administering medications as ordered. A quarterly MDS assessment documented moderate cognitive impairment, a need for partial to moderate assistance with bed mobility and transfers, occasional bladder incontinence, and consistent bowel continence. Physician orders included MiraLAX oral powder 17 gm by mouth once daily for constipation, dated 01/30/26. The resident’s daughter reported that the resident was not receiving medications as prescribed, stating that staff left medications in the room without ensuring they were taken, and then signed the MAR as if they had been administered. During a medication pass observation on 02/09/26 at 11:23 A.M., an LPN was administering morning medications for the resident and confirmed that the ordered MiraLAX was not available, stating the resident would have it by the next day. Despite the medication not being available or given, the LPN signed the MAR indicating that the MiraLAX dose for 02/09/26 had been administered. Subsequent record review on 02/10/26 showed the MiraLAX scheduled for 9:00 A.M. on 02/09/26 was documented as given, with no progress notes or MAR notes explaining the discrepancy or addressing the missed dose. In an interview on 02/10/26, the LPN confirmed that the MiraLAX was not available, that the resident did not receive the medication on 02/09/26, and that the MAR had been signed as if it had been administered, without any corrective note entered in the medical record. This conduct was inconsistent with the facility’s charting and documentation policy, which requires that all services provided be documented in an objective, complete, and accurate manner and that medication administration be accurately recorded in the medical record.
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