F0759

E

Medication Errors and Falsified MAR During Medication Pass

Hayward, California Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

Surveyors identified a medication error rate of 17.39% when four errors were observed out of 23 opportunities during a medication pass for one of nine residents (Resident 2). During a medication pass observation, LVN 1 administered six medications to Resident 2: Docusate Sodium 250 mg, Hydrochlorothiazide 12.5 mg, Metoprolol Tartrate 25 mg, a multivitamin, Senna 8.6 mg, and Vitamin B12 2000 mcg. A review of Resident 2’s physician orders dated 3/5/26 showed that four additional medications scheduled for 9:00 a.m. were ordered but not administered at the time of observation: Aspirin 81 mg delayed release for CVA prophylaxis, Folic Acid 1 mg for supplementation, Vitamin C 250 mg for supplementation, and Vitamin D3 25 mcg for supplementation.

A concurrent review of the Medication Administration Record (MAR) revealed that LVN 1 had signed these four medications as given at 9:00 a.m., despite not administering them during the observed medication pass. When questioned by the DON, LVN 1 admitted to falsely signing the MAR for these medications without actually giving them. The DON stated that LVN 1’s actions were unacceptable, involved failure to administer ordered medications, and constituted falsification of the MAR, and further stated that this omission placed Resident 2 at risk for poor bone health and nutritional deficiencies. The facility’s medication administration policy indicated that medications shall be administered in a safe and timely manner as prescribed, and that the individual administering the medication must initial the MAR on the appropriate line after giving each medication.