- Date
- 11/30/2023
- Report number
- OR0004713100
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Findings
- Staff 2 (RN) stated that on or November 30, 2023, Resident 1 was given the incorrect dose of a pain medication and had no negative outcome. Physician orders for Resident 1, dated on or about December 01, 2023, indicated Resident 1 was to receive 2.5ml of liquid Oxycodone (for pain) every eight hours or as needed for "severe pain." A facility Medication Error Report, dated November 30, 2023, indicated that Resident 1 had been administered 0.25 ml of his/her liquid Oxycodone instead of the prescribed amount of 2.5 ml at 5:00pm, due to staff measuring the liquid Oxycodone inaccurately. It was determined the facility failed to carry out medication orders as prescribed.