Failure to Document Evening Medication Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to follow its medication administration and documentation policies for one resident on a specific evening medication pass. The resident, admitted with idiopathic pulmonary fibrosis and chronic respiratory failure with hypoxia, had multiple scheduled medications between 8:00 PM and 10:00 PM on December 31, 2025, including antihypertensives (losartan, amlodipine, carvedilol), lipid-lowering agents (atorvastatin, ezetimibe), a nutritional supplement (Pro-Stat), an antiplatelet (ticagrelor), a neuropathic pain medication (gabapentin), and pirfenidone for respiratory failure. Review of the December 2025 MAR showed that for this date, there were no nursing signatures or documentation indicating that any of these scheduled evening medications were administered. During a concurrent telephone interview and record review, the DON confirmed that the MAR lacked documentation that the resident received the scheduled 8:00 PM to 10:00 PM medications on that date. In a separate telephone interview, the LVN assigned to administer these medications stated that he did give all of the resident’s scheduled evening medications but forgot to document them on the MAR. He acknowledged that he should have signed the MAR immediately after administering the medications rather than waiting until the end of his shift. Facility policies titled “Specific Medication Administration Procedure” and “Medication Administration” required the licensed nurse to document medication administration in the MAR/EMAR after giving the medications, which was not done in this instance.
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