The findings of the on-site investigation, conducted 04/09/24 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
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, conducted during a site visit on 02/01/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 12 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). Findings include, but are not limited to:
A review of Residents 1, through 12's, Medication Administration Record (MAR), Progress notes, dated 11/03/23 through 11/12/23, and in house investigation dated 11/10/23 through 11/13/23 that was reported to APS (Adult Protective Services) confirmed the following medications were not administered.
1) Resident 1 had a physician order for Levothyroxine 0500, to administer one time daily at 5 am. Missing doses were 11/05/23, 11/07/23, 11/08/23, and 11/09/23.
2) Resident 2 had a physician order for Levothyroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23.
3) Resident 3 had a physician order for Levohtyroxine 0500 to administer one time daily at 5am. Missing doses were 11/04/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, and 11/11/23.
4) Resident 4 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23, and 11/12/23.
5) Resident 5 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23.
6) Resident 6 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23.
7) Resident 7 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23, 11/11/23, and 11/12/23.
8) Resident 8 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/07/23, 11/08/23, and 11/09/23.
9) Resident 9 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23.
10) Resident 10 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/03/23, 11/07/23, 11/08/23, and 11/09/23.
11) Resident 11 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23.
12) Resident 12 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23 and 11/12/23.
In an interview on 02/01/24 at 10:25 am, Staff 1 (ED) and Staff 2 (Health and Wellness director) confirmed they were aware of the incident, and had reported the incident to APS as required, and the employee involved had been counseled extensively and completed multiple Relias courses on medication errors. Staff 2 stated that physicians and families were notified of the medication errors, and that residents affected were monitored and there was no negative outcome to the residents.
The above information was shared with Staff 1 on 02/01/24. S/he acknowledged the findings.
It was confirmed the facility failed to carry out medication and treatment orders as prescribed.
Verbal Plan of Correction:
ED states that they will continue to report all medication errors to the State right away. ED states that they have provided training to all staff and went over medication errors and are reporting to MT, Administration and RN immediately. ED & RN are performing daily clinicals.