F0755

E

Widespread Failure to Document Medication Administration on MARs

Peoria, Illinois Survey Completed on 09-03-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to document medications at the time of administration in accordance with its own Medication Administration policy, which requires staff to initial the Medication Administration Record (MAR) immediately after administering medications and prohibits pre‑signing or post‑signing. Surveyors’ review of MARs for multiple residents in August 2025 showed numerous missing documentation entries for ordered medications over multiple days. The Director of Nursing verified the missing documentation and stated that insufficient staffing contributed to staff not documenting medications administered.

For one resident with Type 2 Diabetes Mellitus without complications, physician orders required Humulin R insulin with meals and Lantus SoloStar insulin twice daily. The MAR for this resident from August 1–27, 2025, showed that both Humulin R and Lantus SoloStar were not recorded as given on six separate dates. A registered nurse later stated that she had been the nurse for that resident on one of the affected weekends and did not know why she had not recorded administering those insulins.

For eight additional residents, MARs dated August 2025 showed that numerous routine and PRN medications, including cardiovascular agents, psychotropics, inhalers, insulin, pain medications, and other chronic disease therapies, were not documented as administered multiple times throughout the month. For several of these residents, individual medications were not documented as given 5 or more times, and in many cases 7–10 or more times, between August 1 and August 25, 2025. These findings collectively demonstrate a pattern of failure to document medication administration as required by facility policy for all nine residents reviewed for medication administration.