Class III

0054 – Medication – Records

Based on record review and interview, the facility failed to maintain an accurate and updated Medication Observation Records (MOR). for 1 of 2 sampled residents. (Resident#1).

The findings include:

(date) at 9:20AM the 2016 MOR for Resident#1 was reviewed and listed: Flexeril 10mg Tab Take 1 by 3 times a day as needed for Spasms. The Flexeril was listed on the front of Resident#1’s MOR as . There was no signatures on the front of the MOR. Further review of the MOR revealed (on the back of the MOR in the notes section): Date:  Time: 7A, InitialsPR ,w Dose (Line through box), Route (Line through Box), Results or Response (line through box),

Noted: 8AM, Nurses Signature: PR. During an interview with Resident#1 on (date) at 9:15AM confirmed he had not received any morning medication due to having his dressing changed by his Home Health Nurse, and was late coming to receive his medications.

During an interview with Staff C (unlicensed staff) revealed the Flexeril had been signed as if it were given to Resident#1 at 7AM. Staff C stated Resident#1 requested the medication and stated he had not received any medications this morning. Staff C stated she attempted to contact the night shift staff via phone but was unable to make contact. Staff C assisted Resident #1 with taking the medication and stated she would follow-up with the Administrator as to how to correct and document on the MOR to reflect the medication was not given at the time it was initially signed for. Further review of Resident #1’s MOR at 12:00PM revealed Staff C had not signed for giving the morning (Flexeril -10mg), and the signature for medication given at 7AM had not been changed or corrected.

During an interview with the Administrator and Manager at on (date) at approximately 4:10PM, they
stated they were not sure what happened but they acknowledge the findings and stated they would
continue to look into it.

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