Incomplete and Inaccurate MAR Documentation for Morning Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident when nursing documentation in the Electronic Medication Administration Record (MAR) and the Controlled Substance Register was incomplete and inconsistent. Facility policies required nurses to document the time and date of all medications administered in the MAR immediately after administration, and to document when medications were withheld or not given, including the reason. Despite these policies, the resident’s February MAR showed multiple morning medications on a specific date coded as held (H) due to the previous shift nurse not having documented administration. The resident, admitted in December 2023, had multiple diagnoses including Parkinson’s disease, atherosclerotic heart disease, hypercholesterolemia, hypertension, dysphagia, rheumatic aortic insufficiency, malignant neoplasm of the breast, and thyroid disorder. Active orders for February included several scheduled medications such as antihypertensives (amlodipine, losartan), aspirin, carbidopa-levodopa, letrozole, hyoscyamine, Miralax, senna, Colace, atropine drops, Lexapro, albuterol, and morphine sulfate solution. On the date in question, the MAR indicated that the morning doses of atropine, hyoscyamine, Miralax, Lexapro, morphine, and multiple 9:00 A.M. medications were all marked as held because the prior nurse had not completed documentation, even though the Controlled Substance Register showed morphine as administered that morning, creating a discrepancy between records. Interviews clarified the sequence of events leading to the incomplete and inaccurate documentation. The ADON, who relieved the morning nurse partway through the day, observed that the resident’s morning medications were not signed off in the Electronic MAR and confirmed with the morning nurse that the medications had been administered but not documented. The ADON stated that the nurse went home without signing off the medications. A nurse on the later shift reported that when she began her medication pass, the Electronic MAR for the resident’s morning medications was in red, indicating no documentation of administration, and she then documented the medications as held due to the previous nurse not completing documentation so she could proceed with her own medication administration. The morning nurse later acknowledged by telephone that she had administered the resident’s morning medications but failed to sign them off in the Electronic MAR before leaving, contrary to facility policy and the DON’s stated expectations.
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