Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 08/04/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
cc:cubic centimeter
CG:caregiver
cm:centimeter
F:Fahrenheit
HH:Home Health
HS or hs:hour of sleep
LPN:Licensed Practical Nurse
MA:Medication Aide
MAR:Medication Administration
Record
MCCMemory Care Community
mg:milligram
ml:milliliter
O2 sats:oxygen saturation in the
blood
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
RN:Registered Nurse
SP:service plan
TAR:Treatment Administration
Record
tid:three times a day
Based on interview and record review, it was confirmed the facility failed to carry out medications as prescribed. Findings include:
Compliance Specialist (CS) reviewed Resident #1 (R1) and Resident #2 (R2) medication administration records (MARs) and progress notes for July 2022 as
well as the facilities policy and procedures for medication errors. CS identified that on 7/25/2022 R1 was given R2 ' s medication. A same day incident report and proper notifications were made. The medication error was followed by alert charting for R1.
Interviews on 8/4/2022 with Staff #1-3 were aware of the medication error. The facility proceeded to investigate, notify physicians, obtain new written orders as needed, created individual service plan, and notified local adult protective services
Verbal Plan of Correction:
The facility documented the incident, filled out a med error report and followed up per their policy and procedure. Training was provided to med tech and the medication cups are now being labeled with more information to easily identify correct resident.