Eden Assisted Living Home

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan dated May 6, 2023. The service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed a medication order signed by a medical practitioner, dated April 23, 2023, for Escitalopram 10 mg (milligrams) every day. 3. A review of R1's medications revealed a medication bottle containing Escitalopram 10 mg. The surveyor observed Escitalopram in R1's medication organizer. 4. A review of R1's medical record revealed a Medication Administration Record (MAR) dated June 2023. The surveyor observed Escitalopram was not listed on the MAR. 5. In an interview, E1 acknowledged the Escitalopram administered to R1 was not documented in R1's medical record. E1 reported R1 received the aforementioned medication as ordered. However, the administration of the aforementioned medication was not being documented in the MAR as required.