Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately reflected the administration of medications for two residents. For one resident with multiple diagnoses including type 2 diabetes, foot ulcer, and morbid obesity, the March 2025 Medication Administration Record (MAR) lacked documentation of morning medications being administered on a specific date. The ordered medications included several critical prescriptions such as mag ox, fluoxetine, buspirone, pantoprazole, metformin, meloxicam, losartan, iron-vitamins, aspirin, and amlodipine. The Director of Nursing (DON) confirmed that an agency RN was scheduled and observed administering medications but did not sign off on the MAR before leaving her shift. For another resident with complex conditions such as multiple sclerosis, schizoaffective disorder, narcolepsy, and chronic pain syndrome, the February 2025 MAR showed no documentation of several scheduled medications being offered or administered on multiple occasions. These included riboflavin, vitamin D, Zyrtec, guaifenesin, Keppra, modafinil, senna S, baclofen, sucralfate, and simvastatin. The DON was unable to provide further details regarding the lack of documentation for these medication administrations.