The findings of the on-site investigation, conducted on 08/17/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MT:            Medication Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

Based on interview and record review, conducted during a site visit on 08/17/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but not limited to:

Resident 1's signed physicians order, July through August 17th 2023 Medication Administration Records (MARs), June through August 17th  2023 progress notes, and Incident Report form dated 07/27/23 indicated that on 07/11/23, Resident 1's Trazadone was to be changed from 25 mg to 12.5 mg, however, staff continued to administer the 25 mg dose until 07/27/23 when the error was caught.

During an interview, Staff 1 (ED) stated Resident 1's medication was supposed to be cut in half, however, the order was not put in the system correctly. S/he stated the doctor was notified and there were no adverse effects. Staff 1 also stated the incident was reported to APS.

The findings were reviewed with and acknowledged by Staff 1 on 08/17/23.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: ED stated 3 checks in place for new orders. MT does first check, RCC does the 2nd check, and RN does the 3rd check. There will be training on 8/18/23 with the corporate RN on medication administration and then additional training for all med techs before September 10th 2023.