The medical assistant, identified as "MA B" in inspection records, told investigators on November 17 that they documented medications in the electronic medical record "after each individual resident." When asked about the discrepancy, MA B said they thought the resident's family had taken him out for the weekend but couldn't remember which day.
The resident in question had not returned to the facility at all.
During her interview at 11:56 p.m. the same day, the facility's administrator acknowledged the severity of the violation. She said every resident could be affected if staff members were documenting that medications were given when the resident wasn't present at the facility. The practice raised questions about whether medications were being given to the right person at the right time, she told inspectors.
The Unit Manager confirmed during a 1:28 p.m. interview that once the resident left, "they did not return to the facility."
Yet the medication administration record continued showing drugs as administered.
The Director of Nursing explained the facility's standard protocol during her 11:36 a.m. interview. Staff were supposed to chart immediately after giving medications and document in the laptop that the medication was administered. The expectation was for staff to "lay eyes on the resident, follow the rights of medication and were giving medications at the right time to the right person."
None of that happened with the resident who was no longer there.
The facility's own policy, revised in June 2019, specifically addresses this scenario. The Medication Administration and Management policy states that staff must document medication as given "in the correct slot of MAR, before going to the next patient/resident." If a resident isn't in their room, staff should "flag the MAR and follow the guidelines when the patient/resident is located."
The medical assistant didn't flag anything. They just kept charting medications as given.
The Director of Nursing told inspectors she interviewed residents to ensure they received proper care and observed staff to verify they were following protocols. Those safeguards failed to catch the falsified documentation.
Federal inspectors classified the violation under medication administration requirements, finding minimal harm or potential for actual harm to few residents. But the administrator's own assessment suggested broader implications for medication safety throughout the
The case raises questions about what happened to the medications that were supposedly administered to the absent resident. When drugs are documented as given but the intended recipient isn't present, the medications either weren't dispensed at all or went somewhere else entirely.
MA B's confusion about whether the resident was on a weekend pass versus permanently discharged suggests inadequate communication about resident status among medication staff. The medical assistant's uncertainty about basic facts regarding resident whereabouts occurred while they held responsibility for documenting controlled substances and prescription medications.
The facility's electronic medical record system apparently lacked safeguards to prevent documentation of medication administration for residents who weren't present. The technology designed to improve accuracy and accountability instead enabled the falsification.
During the November 17 inspection, investigators found the violation represented a breakdown in multiple safety systems. The medical assistant failed to verify the resident's presence. Supervisory staff failed to catch the discrepancy during routine oversight. The electronic documentation system failed to flag impossible entries.
The administrator acknowledged that falsified medication records could affect every resident in the facility by undermining confidence in whether any medications were being properly administered to the correct people at the correct times.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At Faith Memorial from 2025-11-17 including all violations, facility responses, and corrective action plans.