F0755

E

Failure to Document Controlled Medication Administration on MAR

Chico, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medication administration documentation for six sampled residents when a licensed nurse did not sign the medication administration record (MAR) after administering medications, including controlled substances. Facility policies titled “Medication Administration” and “Completion and Correction” required that the person administering medications document the date and time of administration in the resident’s medical record and that professional documentation be complete and accurate. Despite these policies, review of records and interviews showed that medications were documented as given on the narcotic sign-out sheets but were not signed on the MAR by Licensed Nurse (LN) B.

Resident 1, admitted with anxiety and not their own responsible party, had a physician’s order for Xanax 0.5 mg every six hours as needed for anxiety. The Director of Nursing (DON) confirmed that narcotic sign-out sheets for two dates showed LN B administered Xanax at 3:00 p.m. and 9:00 p.m., but these doses were not signed on the MAR. Resident 2, admitted with muscle spasms and their own responsible party, had an order for Percocet 5-325 mg every six hours as needed for moderate pain. The DON confirmed that the narcotic sign-out sheet showed LN B administered one tablet at 9:00 p.m., but this was not documented on the MAR.

Resident 3, admitted with Parkinson’s disease with dyskinesia and their own responsible party, had an order for Norco 5-325 mg, two tablets every six hours as needed for severe pain. The DON confirmed that narcotic sign-out sheets for two dates showed LN B administered two tablets at 3:00 p.m. and 9:00 p.m., but these administrations were not signed on the MAR. Resident 4, with chronic pain syndrome and their own responsible party, had an order for Norco 5-325 mg as needed for moderate or severe pain; narcotic sign-out sheets showed LN B administered one tablet on two early-morning occasions, but these were not signed on the MAR. Resident 5, admitted with chronic pain, had an order for Percocet 10-325 mg every six hours as needed for moderate pain, and Resident 6, admitted with chronic pain syndrome, had an order for Norco 10-325 mg every six hours as needed for moderate to severe pain. For both residents, the DON confirmed that narcotic sign-out sheets showed LN B administered one tablet on an early-morning date, but these doses were not documented on the MAR. LN A and the DON both stated that the narcotic log and MAR should match and that failure to sign the MAR could result in medication errors, including double dosing or giving medications too early. The Administrator confirmed that LN B did not document the administered medications on the MAR.