- Date
- 9/12/2024
- Report number
- CALMS - 00068458
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- A review of Resident 1’s September 2024 MAR and progress notes, and physician orders indicated the following: Order effective 08/28/24 for Mirtazapine 15 MG tab (Remeron): Take 1 tablet by mouth nightly for mood; On 09/02/24, 09/15/24, and 09/16/24 Mirtazapine was documented in MAR as not given due to “med not available” or “wrong dosage in med cart”; Progress note dated 09/17/24 at 1:43pm by Staff 2, reported Mirtazapine dose was changed from 7.5 MG nightly to 15 MG nightly, however, on 09/15 and 09/16 resident did not get their med because staff thought they did not have it, when they did, and a couple of days between 8/28-9/16, resident was given 7.5 MG instead of 15 MG; Order effective 06/28/23 for Flutic/Salmet 232/14MCG Respi: Inhale 1 puff by mouth every 12 hours Rinse mouth and spit after use for Shortness of breath; On 09/03/24, Flutic/Salmet 232/14 MCG Respi was not administered due to “cannot find in med cart”. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 10/02/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed.