Heart to Heart Adult Care Home

Based on record review and interview, the manager failed to ensure a resident's medical record contained the name and signature of the individual administering medication, for two of two residents sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. A review of R1's (received medication administration) medical record revealed a signed medication order dated August 2023, for the following medication: -Paroxetine 20 mg take one tablet daily 2. A review of R1's medication administration record (MAR) for November 2023, listed Paroxetine. However, the MAR did not contain the name and signature of the individual administering the medication for the 8:00 PM administration on November 8, 2023. 3. A review of R2's (received medication administration) medical record revealed a signed medication order dated May 2023, for the following medication: -Atorvastatin 40 mg take one tablet at bedtime 4. A review of R2's medication administration record (MAR) for November 2023, listed Atorvastatin. However, the MAR did not contain the name and signature of the individual administering the medication for the 8:00 PM administration on November 8, 2023. 5. In an interview, E1 reported the medication was administered to R1 and R2, however, E1 forgot to sign the MAR. E1 acknowledged the medical record for R1 and R2 did not include the name and signature of the individual administering the medication.