Inaccurate MAR Documentation for Controlled Psychotropic Medication
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving psychotropic medication. The resident, an elderly female with late-onset Alzheimer's disease, anxiety disorder, and a mood disorder with manic features, had a care plan addressing psychotropic medication use and an order for alprazolam 1 mg at bedtime. On a January date, the controlled drug record showed that the alprazolam dose was not provided, while the January 2026 MAR documented that the same dose was administered at 8:00 PM by an LVN. The resident’s significant change MDS showed a BIMS score of 01, indicating severe cognitive impairment. During interview, the LVN stated she signed the MAR first for the alprazolam dose, then went to check on the resident and did not administer the medication because the resident was already asleep. She reported that she did not remove the alprazolam from its packaging and documented on the controlled drug record that none was given. The LVN acknowledged that the correct process was to check the resident, retrieve the medication, sign the controlled drug record, administer the medication, and then sign the MAR as administered, and that she should have corrected the MAR entry but did not. The DON confirmed that the LVN was responsible for the medication administration and documentation on that date, that the MAR showed the medication as given while the controlled drug record and narcotic count showed it was not, and that facility policy required documenting on the electronic MAR as medications are administered, not before or after.
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