The documentation violations occurred over three days in July, with licensed staff marking their initials on medication records for drops that wouldn't arrive at the facility until July 20. The patient, admitted in May 2024 following a stroke that caused paralysis and speech problems, also suffered from anxiety, bipolar disorder and major depression.
On July 17, nursing staff noted the resident's left eye appeared red, "like a blood vessel had broken." A doctor ordered polyethylene glycol eye drops twice daily for the bloodshot condition.
That same evening at 9:09 PM, an electronic medication record documented the new order but noted "Waiting pharmacy delivery."
Two days later, on July 19, another note confirmed an over-the-counter form had been faxed to the pharmacy, still "Waiting delivery."
By July 20 at 5:54 AM, nurses were still documenting the eye redness and noting they were waiting for the drops to arrive.
Yet the facility's medication administration records told a different story. While the July 17 evening dose was properly marked as not given with a "9" code and nurse initials, the next three doses were signed off as administered. Check marks and nurse initials appeared for the July 18 morning and evening doses, plus the July 19 morning dose.
Licensed Practical Nurse #13 had signed off the July 18 evening dose as given. When inspectors interviewed her on August 13, she confirmed signing the record. But when shown the medication audit details proving the drops weren't dispensed to the facility until July 20, she couldn't explain the discrepancy.
"LPN #13 was asked how she was able to give the drops to Resident #1 when the drops had not been received at the facility until 7/20/25," the inspection report stated. "LPN #13 stated that she could not remember, she could have documented that she gave the drops in error."
The Director of Nursing confirmed the violation when shown the evidence. "So 3 nurses signed off that the drops were given and they were not yet delivered to the building," the director acknowledged.
According to the National Library of Medicine's medication administration standards, the sixth right of medication administration requires correct documentation immediately after giving medication. Signing off on medication that wasn't administered violates this principle because the documentation doesn't reflect actual care provided.
The resident's condition made accurate medication administration particularly important. The stroke had left them with hemiplegia and hemiparesis, partial paralysis affecting one side of the body, along with aphasia that impaired their ability to communicate. Their psychiatric conditions, including generalized anxiety disorder, bipolar disorder and major depression, added complexity to their care needs.
The medication mix-up occurred during a vulnerable period when the resident was experiencing new eye problems that required prompt treatment. The redness in their left eye, described as appearing like a broken blood vessel, had prompted the urgent medication order on July 17.
Staff continued documenting the eye condition even as they falsely recorded giving treatment. The July 20 morning nurse's note mentioned "redness noted left eye sclera" while still noting they were waiting for delivery of the prescribed drops.
The Nursing Home Administrator acknowledged awareness of the problem when informed by the Director of Nursing, according to the inspection report.
The violation affected medication safety protocols that protect residents from receiving wrong medications, incorrect doses, or missed treatments. When nurses sign off on medications not actually given, it creates gaps in the medical record that can lead to dangerous dosing errors or delayed recognition of treatment failures.
Federal inspectors classified the harm level as minimal, but the documentation violations represented a breakdown in basic medication safety practices. The resident's complex medical conditions, including the recent stroke and ongoing psychiatric disorders, made accurate medication tracking essential for their recovery and wellbeing.
The eye drops finally arrived on July 20, three days after being ordered and after three doses had been falsely documented as administered. The inspection found that few residents were affected by the documentation problems, but the case highlighted systemic issues with medication administration oversight at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Rehabilitation and Wellness Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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