F0842

D

Incomplete and Inaccurate Medication Documentation for Two Residents

San Antonio, Texas Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete, accurate, and systematically organized medical records for two residents. For the first resident, an adult female with muscle weakness and low back pain, the medical record included a physician’s order for Methocarbamol 750 mg by mouth three times daily for muscle spasms. The Medication Administration Audit Report showed the medication was scheduled for administration at 9:00 PM on 03/03/2026, but the record reflected administration at 06:03 AM on 03/04/2026 instead. The medication aide stated she was supposed to administer medications within one hour before or after the scheduled time and acknowledged she forgot to document immediately after administration because she was helping other staff before clocking out, although she stated she always ensured medications were given on time. The resident reported receiving medications on time, but the documentation did not accurately reflect the time of administration as required by facility policy, which directs staff to sign the MAR after administering medication.

For the second resident, an adult male with an anxiety disorder, cognitive communication deficit, memory problems, and severely impaired decision-making, the facility had a care plan and physician’s orders requiring monitoring for side effects of antianxiety medication. The order specified that staff should observe for behaviors and side effects such as drowsiness, slurred speech, dizziness, nausea, and aggressive or impulsive behavior, and document “Y” if the resident was free of side effects and “N” if side effects were present, with further documentation in progress notes if “N” was recorded. The January 2026 Medication Administration Record showed that an LVN documented “N” on two daytime shifts, indicating the presence of side effects, but there were no corresponding progress notes describing any side effects on those dates.

Interviews revealed that both the ADON and the LVN found the wording of the antianxiety monitoring order confusing, particularly the requirement to use “Y” for no side effects and “N” for the presence of side effects. The LVN stated that when he marked “N” on the MAR, he intended to indicate that the resident was not experiencing side effects, and that he would have documented in the progress notes if side effects had been present. The ADON acknowledged the order’s wording was confusing and stated it was affecting nursing documentation. Observations on the survey date showed the resident did not respond to questions and was not exhibiting side effects or behaviors related to the antianxiety medication, but the existing records did not accurately reflect the resident’s status due to the misinterpretation and incorrect use of the “Y” and “N” indicators on the MAR.