Print Inspection: TD9M

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 9/15/2022.  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) medication administration records (MARs), progress notes for August 2022 as well as the facilities policy and procedures for medication errors. CS identified that on 8/29/2022 R1 was given two doses of medication X. A same day incident report and proper notifications were made. The medication error was followed by alert charting for R1.

Interviews on 9/15//2022 Staff #1 (S1) and Staff #2 (S2) were aware of the medication error. The facility proceeded to investigate, notify physicians, obtain new written orders as needed, 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.