AMERICAN DREAM HOME II, LLC

Based on documentation review, record review, and interview, for one resident reviewed, the manager failed to ensure documentation of medication administration included the the name and signature of the individual administering medication. The deficient practice posed a health and safety risk to a resident if the facility did not properly document medication administration for a resident, and the Department was provided false and misleading information.

Findings include:

1. In record review, R1's medication administration record (MAR), dated July, 2024, included documentation R1 received Glucosamine, Montelukast, Tamsulosin, and Temazapam medications daily in July. The MAR included documentation signed by E2 which indicated the medications were administered by E2 everyday on each shift.

2. R1's MAR included documentation R1 was administered Montelukast 10mg daily at 8:00am July 1 - 25, 2024. However, E2 reported [E2] did not administer the Montelukast medication for a couple of days on or around July 22 - 25, 2024.

3. During an interview, E2 reported [E2] withheld the medication; however, the MAR was signed inadvertently, with E1's initials, indicating the medication was administered.

4. In documentation review, a facility policy titled, "Medication Administration," page 114, documented, "3. For each employee authorized to administer medications; and will be placed on a list of medication approved caregiver. This list will be found in each file containing the current and filed "Medication Administration Records (MAR)... Immediately after giving medication document the administration on the ... MAR... Documentation that the medication was given will be recorded on the MAR by recording the medication giver's two-digit initials inside the square at the intersection of the date and the time for the given medication..." The facility did not have a list of medication approved caregivers.

5. During an interview, E1 reported E1 and E2 administered medication to residents. E1 said E2 prepared the medication for administration, while E1 administered the medication to the residents. E1 and E2 acknowledged R1's MAR did not include documentation of the name and signature of E1, who administered the medication to R1, and E1 signed the MAR for the administration of the Montelukast medication, when the medication was not administered to R1.

Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Findings include:

1. In documentation review, the facility's medication policies and procedures for medication administration did not include documentation of review and approval by a medical practitioner, registered nurse, or pharmacist.

2. During an interview, E1 reported the policies were reviewed; however, acknowledged the policies did not include documentation of the review and approval by a medical practitioner, registered nurse, or pharmacist and acknowledged the requirements had not been met.

Based on documentation review, record review, and interview, for one resident reviewed, the manager failed to ensure medication was administered to a resident in compliance with a medication order. The deficient practice posed a health and safety risk to residents, if the facility did not administer medications in compliance with a medication order, and a resident did not receive the required medication.

Findings include:

1. In documentation review, the Department received a report from O1 and O2; which documented the facility did not administer Montelukast medication to R1, in accordance with the medication orders.

2. In record review, R1's medical record included a medication order for Montelukast 10 mg (Singular), take 1 tab PO QD for allergies. R1's medication administration record included documentation R1 was administered the medication daily at 8:00am July 1 - 26, 2024.

3. During an interview, E2 reported [E2] did not administer the Montelukast medication to R1 for approximately two days between July 22 to July 25, 2024. E2 couldn't remember which days the medication was withheld, and reported the medication was not administered due to concerns for R1's health. E2 acknowledged not having a medication order to stop the medication. E1 and E2 acknowledged the medication was not administered to R1, as ordered; however, reported the facility was now aware a medication must be administered and/or discontinued in compliance with a medication order.