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Based on record review and interview, the facility failed to administer medications as ordered. This affected three (Patients #2, #3 and #6) of ten medical records reviewed. This had the potential to affect all patients being administered medications by the facility. The facility census was 14.

Findings include:

1. Review of the medical record for Patient #2 revealed an admission date of 07/27/21.

Review of the Medication Administration Record (MAR) revealed Patient #2 had a multivitamin 1 tablet daily ordered. On 08/11/21, there was no documentation the multivitamin was administered.

Magnesium Oxide 400 milligrams (mg) two times a day ordered. The evening dose on 08/03/21, the morning dose on 08/11/21 and the evening dose on 08/15/21 were not documented as administered.

Claritin 10 mg daily ordered. The dosages for 08/06/21 and 08/11/21 were not documented as administered.

Buspar 10 mg two tablets three times a day was ordered. The morning and afternoon doses for 08/07/21 were not documented as administered.

Coreg 25 mg two times a day was ordered. The evening dose for 08/18/21 was not documented as administered.

Levothyroxine 75 micrograms (mcg) at night was ordered. The dose 08/06/21 was not documented as administered

There was no documentation the facility did not have Patient #2's medications.

2. Review of the medical record for Patient #3 revealed an admission date of 01/06/21 and a discharge date of 02/05/21.

Review of the MAR revealed Patient #3 had Vitamin D3 1000 units daily ordered. The dosages for 01/08/21, 01/09/21 and 01/17/21 were not documented as administered.

Trazodone HCL 100 mg at bedtime was ordered. The dosage for 01/07/21 was not documented as administered.

Amlodipine 10 mg daily was ordered. The dosage for 01/25/21 was not documented as administered.

Folic Acid 1 mg daily was ordered. The dosage for 01/25/21 was not documented as administered.

Multivitamin one tablet daily was ordered. The dosages for 01/08/21, 01/15/21 and 01/28/21 were not documented as administered.

Magnesium Oxide 400 mg two times a day was ordered. The evening dosages for 02/02/21 and 02/03/21 were not documented as administered.

There was no documentation the facility did not have Patient #3's medications.

3. Review of the medical record for Patient #6 revealed an admission date of 07/23/21.

Review of the MAR revealed Patient #6 had Topamax 100 mg two times a day ordered. The evening dose for 07/27/21 was not documented as administered.

Omeprazole 20 mg two times a day was ordered. The evening dose for 07/27/21 was not documented as administered.

B-complex 100 mg daily was ordered. The dosages for 07/26/21 and 07/28 were not documented as administered.

Singular 10 mg at bedtime was ordered. The dose for 07/26/21 was not documented as administered.

There was no documentation the facility did not have Patient #6's medications.

These findings were verified by the Compliance Director on 08/30/21 at 11:15 AM.

Review of the policy titled "Medication Administration" (MM 1:024) revealed the nurse is to initial the appropriate medication box after the administration of the medication.