Incident investigation·June 20, 2023

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow-up on an incident report received on 6/15/23. LPA Moleski met with administrator Jennell Revera and explained the purpose of the visit. The incident report states that on 6/9/23, the responsible party of a resident (R1) claimed R1 may have experienced a medication error on 6/6/23. R1's hospital discharge orders state that R1 was to take two 25 mg tablets of a medication per day, for a total of 50 mg daily. The MARs for R1 for the month of June state that R1 was to be given 1 tablet of this medication twice daily, for a total of 50 mg. The medication received by the facility from the responsible party was comprised of 50 mg tablets of this medication. According to the incident report, the tablets were counted during an internal investigation and one tablet was discovered missing. According to Revera, the bottle was already opened when received by the facility. According to the incident report, R1 "did not experience any serious side effects and vitals were within normal limits." According to Revera, the staff member who administered R1's medications on 6/6/23 stated that she had followed the instructions on the MARs. Revera said R1 was admitted on 6/6/23 around 1:30 p.m. The MARs showed tablets were to be administered at 9 a.m. and 5 p.m. The MARs showed the medication was administered on 6/6/23 at 5 p.m. The MARs did not indicate that the medication was administered in the morning. Facility staff sought clarification from the prescribing doctor on 6/7/23 and had a new order sent in for one 50 mg tablet to be taken once per day. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Revera.