F0842

D

Incomplete MAR Documentation for Ordered Midodrine Dose

Pasadena, Texas Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The facility failed to maintain complete and accurate medical records for one resident by not fully documenting medication administration on the Medication Administration Record (MAR). The resident was an older female admitted with multiple diagnoses including anemia, depression, hyperlipidemia, cerebral infarction, hypotension, acute respiratory failure, and type 2 diabetes, and had a BIMS score of 09 indicating moderate cognitive impairment. A physician’s order dated 2/27/2026 directed that Midodrine HCL 10 mg be given orally three times a day, with instructions to hold the dose if systolic blood pressure was greater than 120 or heart rate greater than 60. The corresponding March 2026 MAR reflected this order, but the entry for the 9:00 p.m. dose on 3/12/2026 was left blank, with no documentation that the medication was given, held, or refused, and no vital signs recorded for that administration time.

Multiple staff interviews confirmed that there should be no blanks on the MAR and that all medications must be signed when given or documented if refused or if the resident is not present. LVNs and a med aide consistently stated that if it is not documented, it is considered not done, and that blanks on the MAR could indicate a medication error or that the medication was not given. The DON also stated that there should be no blanks on the MAR and that nurses are expected to follow physician orders and document when medications are given, reiterating that if it is not documented, it was not done. Review of the facility’s Charting and Documentation policy indicated that all services and treatments, including whether a resident refused a procedure or treatment, must be documented in a complete and accurate manner in the medical record, underscoring that the blank MAR entry for this ordered medication was inconsistent with facility policy.