- Date
- 3/24/2023
- Report number
- OR0004131700
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 08/21/23, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents (# 1). Findings include, but are not limited to:
A review of Resident 1's March 2023 MAR showed the following:
* A legend indicating a check mark meant medication was administered.
* An order for Trazadone, for an anxiety disorder, 12.5 mg by mouth in the morning.
* An order for Metoprolol Succinate 50 mg, extended-release tablet for hypertension, by mouth once a day.
Resident 1's March 2023 revealed the following.
* On 03/07/23 and 03/08/23, the 6:30 am dose of Trazadone did not have check marks in the corresponding boxes.
* On 03/07/23, the 6:30 am dose of Metoprolol Succinate did not have a check mark in the corresponding box.
A review of Resident 1's progress note, dated 03/04/23 and 03/06/23, indicated both medications were awaiting refill. In an interview on 08/21/23, Staff 2 stated the lack of a checkmark on the MAR indicated that medication had not been administered. The facility's failure to provide a safe medication administration system for Resident #1 is a violation of Oregon Administrative Rules.