F0842

D

Inaccurate MAR Documentation and Unattended Medications at Bedside

Escondido, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate medical record documentation when a resident’s medications were documented as administered despite being left unattended at the bedside. During an unannounced complaint visit, a resident with a gastrostomy tube and seizure diagnosis was observed lying in bed with eyes closed, while a clear plastic cup containing crushed medications mixed in a tea-colored liquid was found on the bedside table. The resident’s MDS showed the BIMS cognition section was blank. Physician orders directed that several medications, including ascorbic acid, furosemide (with a hold parameter for SBP <100), and a multivitamin with minerals, be given via G-tube in the morning. The MAR for that morning indicated these medications were administered and signed off by a licensed nurse as given.

In an interview, the licensed nurse stated she had left the medications on the bedside table to further dissolve in water she had administered earlier and had already documented the medications as given on the MAR. The DON stated that medications should not be left unattended in any resident rooms and confirmed that the nurse had documented the medications as administered via G-tube. The facility’s “Administering Medications” policy stated that only appropriately licensed personnel may prepare, administer, and document medications, that medications are to be administered in accordance with prescribers’ orders, and that if a drug is withheld, refused, or given at a time other than scheduled, the individual administering the medication must document this. The observed practice and documentation for this resident were inconsistent with these requirements, resulting in inaccurate medical record documentation.