F0658

D

Failure to Document Medication Administration and Complete Ordered Treatments

Sedalia, Missouri Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

Facility staff failed to meet professional standards of practice by not documenting medication administration and not completing ordered treatments for two residents. For one resident with dementia who was cognitively intact and prescribed Levothyroxine, Eliquis, Tamsulosin, and Donepezil, review of the Medication Administration Record (MAR) for a specified month showed no documentation that Levothyroxine was administered on one date, and no documentation that Eliquis, Tamsulosin, and Donepezil were administered on another date. The facility’s Administering Medications policy directed staff to administer medications as prescribed, to initial the MAR after giving each medication and before administering the next, and to circle and annotate the MAR if a drug was withheld, refused, or given at a time other than scheduled.

For a second cognitively intact resident with heart failure, with orders for Metoprolol Tartrate and a wound care treatment to cleanse the right inner buttock and apply Chymosin and zinc twice daily, the MAR for the same month lacked documentation that the wound treatment was completed on multiple specified dates and that Metoprolol Tartrate was administered on one date. Interviews with an LPN, the administrator, the DON, and the ADON confirmed that staff were expected to document all completed medications and treatments, or refusals, in the medical record and to enter a reason if a task was not completed. The ADON stated that he/she and the DON were responsible for monthly review of MARs and treatment records but acknowledged that the February MARs and treatment records were not checked because the ADON was covering the MDS Coordinator position and did not have time to perform the review.