Via Elegante, Galleria

Based on observation, record review, and interview, the manager failed to ensure a medication administered to a resident was accurately documented in the resident's medical record, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan for personal care services including medication administration. 2. A review of R2's medical record revealed a prescription dated October 7, 2023 for, "Furosemide 20 MG Oral Tablet, Take 1 tablet orally in A.M. PRN weight over 150 - HOLD for SBP under 110." 3. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated October 2023. The eMAR documented the medications administered to R1 including, "Furosemide 20 MG, take 1 tablet by mouth every morning as needed for weight over 150 hold for SBP under 110." However, the eMAR included the following dates which had been left blank : - October 23, 2023, however, R2's weight was 156.2 and the medication should have been marked as administered or held; - October 24, 2023, however, R2's weight was 156.4 and the medication should have been marked as administered or held; - October 26, 2023, however, R2's weight was 156.4 and the medication should have been marked as administered or held; and - October 31, 2023, however, R2's weight was 156.6 and the medication should have been marked as administered or held. 4. A review of R2's medical record revealed an electronic Medication Administration Record (eMAR) dated November 2023. The eMAR documented the medications administered to R1 including, "Furosemide 20 MG, take 1 tablet by mouth every morning as needed for weight over 150 hold for SBP under 110." However, the eMAR included the following dates which had been left blank : - November 4, 2023, however, R2's weight was 152 and the medication should have been marked as administered or held; - November 6, 2023, however, R2's weight was 152.2 and the medication should have been marked as administered or held; - November 10, 2023, however, R2's weight was 152.4 and the medication should have been marked as administered or held; - November 11, 2023, however, R2's weight was 153.8 and the medication should have been marked as administered or held; and - November 26, 2023, however, R2's weight was 151 and the medication should have been marked as administered or held. 5. In an interview, E1 and E2 acknowledged the eMAR contained gaps on several days for which the administration of Furosemide had not been documented.