Mcallen Nursing Center

behaviors. LVN A said she administered all medications as ordered, just did not document or check off the medications on the MAR. LVN A said she did not know why, maybe she forgot to check off the MAR. LVN A said the facility instructed them in the past that it was her responsibility to ensure all the documentation was done. LVN A said it was important for documentation to be accurate to show if the resident was compliant with medications and to show the staff followed the orders. On 11/21/25 at 12:30 PM, in an interview with LVN B, she said she worked on 10/27/25 and 10/28/25 with Resident #1. LVN B said Resident #1 did not refuse his medications when she worked with him and he allowed her to do the blood sugar checks. LVN B said she did not have to notify the doctor of any abnormal findings and there were no other indications that Resident #1 had not been administered his medications as ordered. LVN B said she administered Resident #1's medications on 10/27/25 and 10/28/25, including the antianxiety medication and insulin, but possibly forgot to check off the MAR. LVN B said she was in-serviced on medication administration and documentation a few weeks ago. LVN B said she was told it was her responsibility to ensure documentation was completed before leaving for the day. LVN B said it was important for the MAR to be accurate, to ensure they gave Resident #1's medications appropriately, to not give double medications and to prevent medication errors. On 11/21/25 at 3:00 PM, in an interview with the DON, he said he reviewed the documentation and did not find the MARs to be checked off correctly for Resident #1.

The DON said he spoke to the nurses and they all ensured that they administered the medication.

The DON said he will be re-educating staff to ensure they check their MARs before leaving at the end of their shift.

The DON said documentation was important to show whether the medications were given or not and why not.

The DON said the expectation for staff was to ensure all documentation was accurate and completed.

The DON said there were no negative outcomes for Resident #1 or indications that his medications were not administered as ordered, just not documented properly.

Record review of the facility's Medication Administration policy dated 02/10/20 reflected - Purpose: to safely and accurately prepare and administer medication according to physician orders and patient needs. 9.

Administration - document initials on MAR for each medication administered. 10.

Patient refusal - circle initials on MAR and document refusal on back side of MAR.

Record review of the facility's Clinical Document Guidelines policy dated 02/14/20 reflected - Policy: the patient's clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing healthcare services provided to the patient.

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