- Date
- 12/13/2023
- Report number
- OR0004686900
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- On January 5, 2024, with Staff 1, confirmed that the medication error occurred. Staff 1 stated in the interview that three care staff will be advanced to the Med Tech position and are receiving training on the cart. Those same individuals are being delegated for residents who require delegated administration. A review of APS Referral Form Screening dated December 14, 2023, and the facility self report of the dated December 13, 2023, it was indicated that Resident 1 received medication for high blood pressure despite being outside parameters for administration. Medication was to be held if Resident 1's Systolic Blood Pressure (SBP) was below 120, or heart rate was below 60. Resident 1 received high blood pressure medication when their SBP was 116 and heart rate was 56.
On January 3, 2024, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 residents (#1) who received medications.