Inaccurate MAR Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one sampled resident by inaccurately documenting medication administration while the resident was hospitalized. The resident had been admitted with diagnoses including other encephalopathy, unspecified dementia, and generalized muscle weakness, and had multiple active physician orders for medications such as atorvastatin, levothyroxine, docusate, ferrous sulfate, lubiprostone, pantoprazole, quetiapine, and senna. The resident’s Minimum Data Set indicated moderately impaired cognitive skills for daily decisions. Record review showed that the resident was transferred to a general acute care hospital on 2/15/2026 at 7:20 p.m. following an incident in which another resident made physical contact; a head-to-toe assessment revealed no pain or injuries, and the physician ordered transfer for further evaluation. Progress notes documented the transfer on 2/15/2026 and the readmission from the hospital on 2/19/2026 at 3:02 p.m., confirming that the resident was not present in the facility between those dates and times. Despite the resident’s absence, the February 2026 Medication Administration Record showed that LVN 6 documented administration of atorvastatin, quetiapine, senna, docusate, ferrous sulfate, pantoprazole, and lubiprostone on specific dates and times while the resident was at the hospital, and LVN 7 documented administration of levothyroxine and pantoprazole during the same period. In interviews, the ADON confirmed that the resident was at the hospital during these documented administrations and stated that LVN 6 and LVN 7 should have verified the resident’s presence and identity before documenting medication administration, acknowledging that the medical record was inaccurate. The DON also stated that the nurses should not have documented medication administration when the resident was at the hospital and that medications should have been documented as not given, noting that the inaccurate medical record could cause confusion in care. The facility’s charting and documentation policy required that all medications and care be documented promptly and accurately according to facility and regulatory requirements. These failures had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.
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