F0755

E

Failure to Administer and Document Ordered Medications for Two Residents

Signal Hill, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure medications were administered as ordered for two residents, as evidenced by missing administrations and documentation on their Medication Administration Records (MARs). One resident with severe cognitive impairment and multiple diagnoses including COPD, GERD, bilateral hip osteoarthritis, and a bone density disorder had active orders for Alendronate Sodium 70 mg once weekly on Sundays, Omeprazole 20 mg daily, and Synthroid 75 mcg every morning. Review of this resident’s March MAR showed no documented evidence that Alendronate Sodium and Omeprazole were administered at 6 a.m. on 3/1, no documented evidence that Synthroid was administered at 6:30 a.m. on 3/1 and 3/3, and no documented evidence that Omeprazole was administered at 6 a.m. on 3/3. During interview and concurrent record review, the RN Supervisor confirmed these medications were not administered as ordered, and the DON stated that if the MAR was not signed, it meant the medication was not administered.

A second resident, admitted with a left tibia medial malleolus fracture, dementia with moderately impaired cognition, and muscle weakness, was dependent on staff for all ADLs and had an active order for Visine Dry Eye Relief Ophthalmic Solution 1%, one drop in both eyes three times daily. Review of this resident’s March MAR showed no documented evidence that Visine was administered at 6 a.m. on 3/3. The RN Supervisor confirmed that this medication was not administered as ordered. The facility’s 2024 “Administering Medications” policy stated that medications are to be administered as prescribed and that the individual administering the medication must document the date, time, dosage, route, and their signature and title on the MAR, which did not occur in these instances.