complaint·February 19, 2025

Report Continued from LIC 9099... It was alleged that staff mismanaged resident medication. It was reported that medication errors have occurred with routine medications and wrong dosages were being administered. Record review of Resident #1's (R1) medication records and interviews conducted revealed a discrepancy between the prescribed dosage of Temazepam and the actual dosage administered over several days. Initially, R1 had been prescribed a 30mg dosage of Temazepam (1 capsule) to be taken at bedtime. On 09/19/2024, R1’s physician issued a prescription change, reducing the daily dosage to 15mg (1 capsule), with the new dosage intended to take effect on 09/20/2024. However, despite this directive, the medication administration did not reflect the updated prescription. The Centrally Stored Medication and Destruction Record (CSMDR) indicated that the 30mg dosage continued to be administered until 09/21/2024. Furthermore, the change to the 15mg dosage did not occur until 09/22/2024, a full two days after the physician's order. Based on the information obtained during the course of the investigation, the Department has sufficient evidence to support the allegation of “staff mismanaged resident medication”. Therefore, this allegation is deemed SUBSTANTIATED at this time. It was also alleged that staff are not following reporting requirements. It was reported that medication errors were occurring but were not being reported. Record review and interviews conducted revealed that there was no incident report (LIC 624) on file and the department was not contacted in a timely manner in regard to the facility having medication errors and/or administering wrong medication dosage to residents in care. This medication error which was revealed to be wrong dosage administered to the resident through a medication review was not reported or communicated with the Department. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “staff are not following reporting requirements”. Therefore, this allegation is deemed SUBSTANTIATED at this time. Exit interview conducted. A copy of the report and appeal rights were provided.