Incomplete MAR Documentation for PRN Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident receiving pain management. The resident was an older female with multiple significant diagnoses, including cerebral infarction with resulting hemiplegia/hemiparesis, reduced mobility, osteoporosis, muscle weakness, and a history of a displaced comminuted fracture of the left femur. Her comprehensive and quarterly MDS assessments showed intact cognition (BIMS 14) and documented that she received scheduled and PRN pain medications and non-medication interventions for pain. Physician orders included monitoring pain every shift using a 1–10 scale and PRN orders for Meloxicam and Tylenol 325 mg, two tablets by mouth every six hours as needed for mild pain. Following a fall from bed on 1/6/26, a progress note documented that she complained of pain to her left side and was medicated for discomfort. On 1/8/26, the Medication Administration Record (MAR) documented a pain level of 8 for the resident on the night shift (Nocs), but there was no corresponding documentation on the MAR that Tylenol 325 mg was administered that day. A progress note entered on 1/9/26 by an LVN stated that the resident, status post fall, complained of knee pain during the shift and was medicated once with APAP 325 mg as ordered, which she tolerated well. In an interview, the LVN reported that she gave Tylenol when the resident reported pain of 8, that the resident’s pain decreased and she likely went to sleep, and that failure to document on the MAR was probably an oversight, despite having noted it in her paper tablet. The DON stated that her expectation was that nurses document medication administration on the MAR at the time it is given. Facility documents, including the LVN job description and the documentation policy, describe the requirement to complete charting and maintain a concise account of treatment, care, and resident response, underscoring that the missing MAR entry for the administered Tylenol constituted incomplete and inaccurate clinical documentation.
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