Desert Springs Escondido

Based on record review, documentation review and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Record review established that R1's medical administration record was not filled out as administered at 8am for the following medications on October 15, 2024: - Depakote Sprinkles 125mg - Loratadine 10mg - Meloxicam 7.5mg - Famotidine 20mg 2. Record review established that R2's medical administration record was not filled out as administered at 8am for the following medications on October 15, 2024: - Aspirin 81mg - Iron 325mg - Metoprolol Succinate 25mg - Vitamin D3 2000IU - Doxycycline Hyclate 100mg 3. Record review established that R2's medical administration record was not filled out as administered at 7am for the following medication on October 15, 2024: - Levothyroxine 75mcg 4. Documentation review established that the facility had a policies and procedures section titled "Policy and Procedures for Storing, Dispensing and Disposing Controlled Substances." Section A.1.a. of this section contained the following: "The receipt, administration and disposal of controlled substances or drugs must be recorded in a "register". The register must include the balance remaining for each product with a separate record page being maintained for each resident". 5. In an interview, E1 confirmed that R1's medical administration record was not filled out as administered at 8am for the following medications on October 15, 2024, although these medications were given as ordered: - Depakote Sprinkles 125mg - Loratadine 10mg - Meloxicam 7.5mg - Famotidine 20mg E1 also confirmed that R2's medical administration record was not filled out as administered at 8am for the following medications on October 15, 2024, although these medications were given as ordered: - Aspirin 81mg - Iron 325mg - Metoprolol Succinate 25mg - Vitamin D3 2000IU - Doxycycline Hyclate 100mg E1 also confirmed that R2's medical administration record was not filled out as administered at 7am for the following medication on October 15, 2024, although the medication was given as ordered: - Levothyroxine 75mcg E1 also confirmed that the facility had a policies and procedures section titled "Policy and Procedures for Storing, Dispensing and Disposing Controlled Substances." Section A.1.a. of this section contained the following: "The receipt, administration and disposal of controlled substances or drugs must be recorded in a "register". The register must include the balance remaining for each product with a separate record page being maintained for each resident".