F0697

D

Failure to Administer and Document Scheduled Pain Medication

Monterey, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

Failure to provide scheduled pain medication occurred when a resident did not receive their ordered medications as documented on the Medication Administration Record (MAR). During an interview, the resident reported not receiving his medications on 2/13/26, which he stated caused increased pain over the weekend. Review of the resident’s February 2026 MAR showed that medications scheduled for 10:00 a.m. on 2/14/26 were not administered, with the MAR displaying a red indicator for that time, signifying the medications were not given. The Director of Staff Development confirmed that if medications had been administered, refused, or if the resident had been out of the building, the MAR would show documentation and a green background, but none was present. RN A also confirmed there was no documentation that the 10:00 a.m. medications were given on 2/14/26. The facility’s medication administration policy, dated 2001, states that medications are to be administered in a safe and timely manner as prescribed, and that any withheld, refused, or rescheduled doses must be documented, with the administering individual initialing the MAR after each medication is given.

This lack of administration and documentation of the resident’s scheduled pain medications resulted in the resident experiencing increased pain and emotional distress.