F0842

D

Incomplete Medication Administration Documentation for a Resident

Gainesville, Florida Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records for one resident related to medication administration. Physician orders for this resident included Acidophilus 100 mg capsules twice daily, Ascorbic Acid 500 mg tablets twice daily, Eliquis 5 mg twice daily for unspecified atrial flutter, Famotidine 20 mg twice daily for GERD, Insulin Glargine 35 units subcutaneously twice daily for diabetes in a dialysis patient, and Apidra SoloStar 8 units subcutaneously before meals for type 2 diabetes with complications. Review of the resident’s MAR for December showed missing documentation entries for multiple scheduled doses of these medications, including Acidophilus, Ascorbic Acid, Eliquis, Famotidine, Insulin Glargine, and Apidra at specified afternoon/evening administration times.

Interviews with nursing staff revealed that the resident did not like certain LPNs, leading to an informal practice where one nurse would administer the medications while another nurse was responsible for documenting them on the MAR. One LPN stated she gave all of the resident’s medications on a specific date and expected another LPN to document them, while that LPN acknowledged she was supposed to document the medications but must have forgotten. Another LPN reported that, due to the resident’s verbal abuse, another nurse administered the medications while she pulled the insulin and verified with the other nurse that the medications were given, but she believed she became distracted and failed to sign off on the MAR. The facility’s policy on Charting and Documentation required that medications administered and services performed be recorded in the resident’s clinical record by the staff providing care, but this was not followed, resulting in incomplete and inaccurate medical records for the resident.