Incomplete MAR Documentation for Resident Medications
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by allowing blanks on the Medication Administration Record (MAR). The resident was an older female with atrial fibrillation, type 2 diabetes mellitus, GERD, open wounds on the right lower leg and left buttocks, and muscle weakness, who did not self-administer medications and required partial or moderate assistance with personal hygiene. Her admission MDS showed a BIMS score of 12, indicating moderately impaired cognition. Review of her December MAR showed blanks on specific dates for esomeprazole magnesium 40 mg, ordered for GERD, with no documentation to indicate whether the medication was administered, refused, held, or unavailable. Additional daily scheduled orders on other dates were also left blank without any coding or initials. Nursing progress notes indicated that the resident was in the hospital between certain dates and was later discharged home, but the MAR was not coded to reflect her hospital status or any refusals of medication. During interview, the DON stated that staff were expected to enter a code on the MAR rather than leave entries blank, including codes indicating hospitalization or refusal of medications. The facility’s policy on Charting and Documentation required that medications administered be documented and that documentation be complete and accurate. The presence of blank MAR entries for this resident demonstrated that the facility did not follow its own policy or accepted professional standards for complete and accurate medical record documentation.
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