Medication Administration and Documentation Errors for Multiple Residents
Penalty
Summary
Facility staff failed to administer medications according to physician orders and to accurately document administration for three residents. For one resident, a standing order for Calcium Carbonate 500 mg by mouth each morning, in place since 3/22/2025, was listed on the December 2025 MAR, but there was no documentation of administration on 12/5/2025 and 12/26/2025; the MAR boxes for those dates were left blank. During interview, an LPN confirmed that nurses evidence medication administration by checking off the MAR and acknowledged that if it is not documented, it is considered not done. For another resident with an order dated 12/18/2025 for Ciprofloxacin HCL 500 mg by mouth every 12 hours for 7 days for a UTI, the December MAR showed the order starting 12/19/2025, but the 9:00 a.m. and 9:00 p.m. doses on that date were left blank, despite Ciprofloxacin being available in the emergency backup box. For a third resident admitted for respite care, staff failed to administer and/or accurately document Lorazepam Oral Concentrate per a physician order dated 12/4/2025 for 2 mg/mL, 0.25 mL by mouth every 2 hours for anxiety. The December MAR showed the medication as given at 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. on 12/4/2025, and at 4:00 a.m. and 6:00 a.m. on 12/5/2025. However, the narcotic sign-out sheet documented only two doses on 12/4/2025 at 5:30 p.m. and 7:00 p.m., with no entries for the other scheduled times. On 12/5/2025, the narcotic sheet showed doses at 12:00 a.m., 2:00 a.m., and what appears to be 6:00 a.m., with no documented 4:00 a.m. dose. The resident’s comprehensive care plan noted the resident was at risk for adverse reactions and side effects from antianxiety medications and included an intervention to administer antianxiety medications per orders. The LPN described the process for narcotic administration as removing the drug from the narcotic box, signing it out in the narcotic book, and then documenting the dose on the MAR, highlighting the discrepancy between the two records.
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