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F0658
D

Failure to Accurately Document and Administer Scheduled Medication

Montrose, California Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A licensed nurse failed to accurately and timely document medication administration for a resident with diagnoses including dementia and atherosclerotic heart disease. The resident was prescribed several medications, including daily aspirin (ASA) for stroke prophylaxis. On the morning in question, the nurse prepared seven medications for the resident's scheduled 9 AM administration, but did not include ASA among them. Despite not administering the ASA, the nurse signed the Medication Administration Record (MAR) at 8:53 AM, indicating that all scheduled medications, including ASA, had been given. The nurse later admitted to signing the MAR before actually administering the medications, which was not in accordance with facility policy. The nurse also acknowledged overlooking the physician's order for ASA and failing to double-check the orders before documenting administration. The facility's policy requires that the individual administering medications initials the MAR after giving each medication and before administering the next. The Director of Nursing confirmed that signing the MAR before medication administration could result in inaccurate documentation and medication errors. As a result of these actions, the resident did not receive the prescribed ASA as scheduled, and the MAR inaccurately reflected that it had been administered.

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