Print Inspection: G5HQ

Based on interview and record review, conducted during a site visit on 02/27/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (#2). Findings include, but not limited to:

Compliance Specialist (CS) reviewed Resident 2's June 2023 MAR, progress notes, and physician orders which indicated the following:

·Order dated 06/08/23 for oxycodone-Acetaminophen 10-325 Tablet to be given 2 tablets orally morning, noon and night for pain 28 days

·Progress note dated 06/14/23 requesting script for oxycodone that resident has been taking to be resubmitted to pharmacy. Awaiting fax

·Progress note dated 06/14/23 stated Oxy not given in a.m., not available.

·Progress notes dated 06/14/23 stated order on the medication card did not match the order on the emar

·Order dated 06/12/23 for oxycodone-Acetaminophen 10-325 Tablet to be given 1 tablet orally 5 times per day 28 days

·June 2023 MAR shows that between 06/08/23-06/14/23 oxycodone-Acetaminophone 10-325 tab was given 1 tablet five times per day, four hours apart instead of the current order for 2 tablets three times per day

During an interview, Staff 1 (ED) stated the incident had occurred. S/He stated a new order came in on 06/08/23 and a staff member had faxed the doctor for clarification. S/He stated that the new order had not been updated on the MAR and staff were administering the medication following the previous order until the error was noticed on 06/14/23. S/He stated at that time, there had been another order on 06/12/23, to change it back to the previous order which had not been processed yet.

The findings were reviewed with and acknowledged by Staff 1 on 02/27/24.

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

Verbal plan of correction: Final corrective action was given to staff member involved in the incident. Education regarding following physician orders, communication with physician/nurses was proved to all nursing staff on 06/21/23.