- Date
- 8/27/2024
- Report number
- CALMS - 00068442
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- A review of Resident 1’s signed physician orders, dated 08/16/24, revealed an order for “MORPHINE (MSIR) 15 MG TABLET take 0.5 tablets by mouth 3 times daily as needed for pain (Additional ½ tab may be offered for pain 8/16-8/18).“ A review of Resident 1’s 08/01/24 – 08/31/24 MAR revealed the above order was not entered into the MAR. A review of “Suspected Abuse or Unexplained injury reporting form,” dated 08/30/24, revealed “on 8/27/2024 at 4pm MT gave [Resident 1] a PRN of Morphine because [s/he] said [s/he] was in pain. [S/He] has a PRN card for it. End date on the card was 8/18/24. The end date was unnoticed by the MT on shift.” During an interview, Staff 1 (Resident Services Manager) stated Resident 1’s PRN medication should have been added to the MAR, but was not and Resident 1 did not have an order for a PRN pain medication to be given on 08/27/24.