F0842

E

Failure to Document and Verify Night-Shift Medication Administration

Picayune, Mississippi Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records and to document medication administration in accordance with its own policy and accepted professional standards. The facility’s policy on administering medications, revised 8/2/22, requires that medications be administered in a safe and timely manner as prescribed, that the resident be observed taking the medication, and that the nurse document on the EMAR when the medication is administered. A review of the Medication Admin Audit Report for Station B for 12/29/25–12/30/25 showed that 25 residents had medications with no administration time documented and 5 residents had medications documented as administered late by at least one hour. These findings indicated that medication administration could not be verified as accurate and timely for multiple residents on the night shift of 12/29/25.

During interviews, the DON confirmed that facility policy requires licensed nurses to document all medications administered, held, or not administered on the MAR at the time of administration. She acknowledged that there was an impaired nurse working on 12/29/25 and that she relied on LPN #2’s statement that residents’ medications had been administered, without verifying the MAR documentation at that time. LPN #2 reported that she accessed the medication cart and pulled medications for the impaired nurse but did not administer the medications herself, did not document them on the MARs, and did not accompany or observe the impaired nurse during medication administration. LPN #2 further confirmed that she did not visually verify that the correct medications were administered to the correct residents and did not perform any checks or follow-up verification to ensure medications were given as ordered or documented.

Record review for four sampled residents showed specific undocumented medication administrations on the night of 12/29/25. Resident #1, with dementia and a severely impaired BIMS score of 03, had an order for Donepezil 5 mg at bedtime, with no documentation of the 8:30 PM dose. Resident #2, cognitively intact with a BIMS score of 15 and diagnoses including cerebral infarction, hyperlipidemia, glaucoma, diabetes mellitus, and insomnia, had active orders for Crestor, Latanoprost eye drops, Novolog before meals and at bedtime, and Trazodone at bedtime, with no documentation of receiving scheduled 8:00 PM or 9:30 PM medications. Resident #3, cognitively intact with hemiplegia and hemiparesis following cerebral infarction and orders for Accuchecks AC and HS, Gabapentin, Guaifenesin, Keppra, and Lacosamide, had no documentation of receiving any 8:30 PM medications. Resident #4, with senile degeneration of the brain, dementia, and a moderately impaired BIMS score of 9, had orders for Clonidine, Duloxetine, and Gabapentin, with no documentation of receiving any 8:30 PM medications on that date.