Incomplete MAR Documentation for Multiple Medications
Penalty
Summary
The deficiency involves incomplete and inaccurate documentation on the Medication Administration Record (MAR) for one resident. Resident B’s clinical record showed multiple active physician orders for medications including amlodipine for hypertension, aspirin for heart failure, buspirone for anxiety, cholecalciferol for vitamin D deficiency, divalproex for bipolar disorder, metoprolol succinate for hypertension, and polyethylene glycol for constipation. Several of these orders had start dates and, for some, discontinue dates, while others had no stop dates noted. Review of the MAR for the period from 2/1/26 through 2/28/26 revealed missing documentation entries for multiple medications on specific dates and shifts. Specifically, the MAR lacked documentation for administration of amlodipine, aspirin, divalproex, metoprolol succinate, and polyethylene glycol on the morning shifts of 2/12/26 and 2/19/26, and for buspirone at 12:00 p.m. on 2/12/26. These MAR entries were left blank, with no indication whether the medications were given or omitted. During an interview, an LPN stated that the documentation should have been completed on the MAR. The DON provided the facility’s Charting and Documentation policy, which states that medication administration must be documented, confirming that the observed blanks on the MAR were not in accordance with facility policy and accepted standards.
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