Danina's Care Home, LLC

Based on documentation review, observation, interview, and record review, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for six of six total residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency and as the Department was provided false or misleading information. Findings include: 1. A review of facility policies and procedures revealed a policy and procedure titled "Medication Administration, Records and Monitoring" dated January 1, 2023. The policy stated: "The trained caregiver will initial in the MAR and include the date and time the medicine was given to the resident and the medications that were taken...Medication administration records will be filled by the authorized personnel that are doing medication administration and/or assisting in self-medication administration only after observing the resident taking the medication. The time and date will be recorded as well as the initials of the person that administered the medication." 2. During the environmental inspection of the facility, the Compliance Officer observed a medication administration record (MAR) binder with MARs for R1, R2, R3, R4, R5, and R6 inside. 3. A review of the medical records of R1, R2, R3, R4, R5, and R6 revealed MARs for R1, R2, R3, R4, R5, and R6 dated September 2023. However, the MARs revealed no documentation of any medication administered to R1, R2, R3, R4, R5, and R6 in September 2023. 4. In an interview, E3 reported all six residents received medication administration services. E3 reported E1 had previously taken the MAR binder to E1's home to prepare it for September. E3 reported the binder was not available until the morning of the inspection. E3 reported E3 had been unable to document medication administration for September 2023 until the morning of the inspection. 5. A review of R1's medical record revealed medication orders for "Levothyroxine 50 mg (milligrams) 1 tab, 3 times a week [on] Sun. Mon. [and] Tues." and "Levothyroxine 75 mg 1 tab, 4 times a week [on] Wed. Thurs. Fri. [and] Sat." dated June 22, 2023. R1's medical record also contained a MAR dated August 2023. The MAR revealed indicated R1 received "Levothyroxine 50 mg" and "Levothyroxine 75 mg" each day in August. 6. In an interview, E1 reported R1 received R1's "Levothyroxine 50 mg" and "Levothyroxine 75 mg" as ordered, and the administration was incorrectly documented.