Violation Details: OR0004721000

Date
12/20/2023
Report number
OR0004721000
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Allegation
Failed to administer medication as ordered
Result
Substantiated
Rule(s) Violated
Findings
Resident 1 had an order to receive 1 tab of hydrocodone daily. A review of an incident report dated December 21, 2023, revealed that on December 20, 2023,at 5:00 am, Staff 2 gave Resident 1, a half hydrocodone, instead of 1 full tab. The incident report indicated that no side effects or reaction occurred due to the error. On January 5, 2024, 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. Based on interview and record review conducted during a desk review, on January 5, 2024, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents (#1).