Inaccurate MAR Documentation of Fentanyl Patch Removal
Penalty
Summary
The deficiency involves inaccurate medical record documentation related to a fentanyl transdermal patch order for Resident 2. The resident had an order initiated on 2/25/26 for a 12 mcg/hr fentanyl patch to be applied every 72 hours for pain/comfort and removed per schedule. On the February 2026 MAR, the administration entry for 2/25/26 at 12:24 P.M. was coded with "9," which the MAR legend defined as "Other/ See Nurses Notes." A progress note entered at 12:25 P.M. by LN 4 documented that the facility was awaiting delivery of the fentanyl patch, and the DON later confirmed that Resident 2 did not receive a fentanyl patch on 2/25/26 because the medication was not delivered until 2/28/26. Despite the absence of an applied patch, Resident 2's February 2026 MAR showed an entry on 2/28/26 at 11:56 A.M. indicating that a fentanyl patch was removed. During interviews, the DON stated that, based on the controlled drug record, the fentanyl patch had not been applied on 2/25/26 and therefore there was no patch to remove on 2/28/26. The DON confirmed that LN 1 documented removal of the fentanyl patch on the MAR and acknowledged that this documentation was not accurate. The facility's Charting and Documentation policy, revised July 2017, requires that documentation in the medical record be objective, complete, and accurate, which was not followed in this instance.
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