Failure to Administer and Document Prescribed Medications
Penalty
Summary
Facility staff failed to administer prescribed medications to a resident as ordered by the physician. On the evening of 6/19/25, the resident's medication administration record (MAR) showed that scheduled doses of Atorvastatin Calcium and Apixaban were not documented as given, with the MAR left blank for the 9 p.m. administration. There were no progress notes or documentation in the resident's chart explaining the omission, and the resident was present in the facility at the time. The resident reported frequent issues with medication availability and administration, specifically mentioning pain medication. Interviews with facility staff, including the unit manager (RN) and the DON, confirmed that there was no evidence the medications were administered as ordered. The nurse assigned to the resident that evening was an agency nurse who no longer worked at the facility, and staff acknowledged that if medication administration is not documented, it is considered not done. Facility policy requires immediate documentation of medication administration, and review of the MAR at the end of each pass, but these procedures were not followed in this instance.