Incomplete and Inaccurate MAR Documentation for Scheduled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records, specifically the medication administration records (MARs), for one resident receiving scheduled pain medication. The resident, an elderly male with cerebrovascular disease, gangrene, unspecified knee pain, and osteoarthritis, had severely impaired cognition and experienced pain that frequently limited his day-to-day activities. Physician orders dated 3/25/26 showed a standing order for hydrocodone-acetaminophen 10-325 mg every 6 hours for pain related to gangrene, with a start date of 3/9/26 and no end date. Review of the resident’s March 2026 electronic MAR revealed multiple blanks for the scheduled hydrocodone-acetaminophen doses on specific dates and times, with no coding, initials, or documentation to indicate whether the medication was administered, refused, held, or unavailable. Additional review showed that other daily scheduled medications on certain dates were also left blank without any documentation. The facility’s policy required that the person administering medications record administration on the MAR at the time the medication is given, initial the MAR in the space provided, and enter an explanatory note if a regularly scheduled dose is withheld, refused, or given at a time other than scheduled. When the DON and administrator were interviewed, they acknowledged that the electronic MAR contained blanks and suggested that internet interruptions might have led staff to use paper MARs. A paper MAR dated March 19, 2026, for the same hydrocodone-acetaminophen order showed an entry of “ref” with unknown staff initials for one dose, and entries with LVN A’s initials for subsequent doses without any indication whether the medication was administered, refused, held, or unavailable. The section of the paper MAR intended for staff to print their name and initials was completed only by LVN A, and the unknown staff’s identifying information was missing. The resident reported having pain from gangrene and being unsure if he received his pain medication, while a family member stated that nursing staff were sometimes not around when pain medications were due and that hospice had spoken to the facility about ensuring the resident received his pain medications.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.