Failure to Administer Medications as Ordered and Document on MAR
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one of three residents sampled for medication administration. Review of the resident's Medication Administration Record (MAR) for September 2025 revealed multiple missed doses of prescribed medications, including atorvastatin, doxepin, mirtazapine, Singulair, Zyprexa, carvedilol, buspirone, gabapentin, carafate, and hydrocodone-acetaminophen. There were blanks on the MAR for these medications on specific dates, and no explanations for the missed doses were documented in the medical record. Interviews with facility staff confirmed that blanks on the MAR indicated that the medications were either not in the facility or not given, and that the medications in question did not appear to have been administered as ordered. The certified medication aide and the Assistant Director of Nursing (ADON) both acknowledged that the medications had not been signed out or given according to the facility's policy and physician orders. The resident involved was noted to have intact cognition at the time of the deficiency.