Facility Evaluation Report

LPA Tuesday Cabiness conducted a case management visit to follow up on two Special Incident Reports (SIRs) submitted by the facility. The incidents involved (1) a medication administration error, and an un- witnessed altercation between two residents that resulted in minor injuries and police involvement.

According to the SIR and interview with the Executive Director (ED), Resident #1 (R1) was recently prescribed a new medication, intended to be administered three times per week per the pharmacy label and the physician's written order. However, the pharmacy inputs physician orders for residents in a QMAR system that is able to be be read by the facility, that has description and details on RX's written by the primary physician. According to the QMAR, (R1) was to be administered the new RX once a day. But the RX label wrote (R1) was to be administered the RX, (3x) a week.

The error occurred over four days, starting on April 2, 2025. During this period, R1 received the medication daily rather than as prescribed. Staff did not consult the on-duty nurse or verify the dosage instructions with the pharmacy. Once the error was identified, staff immediately informed the Executive Director and the Regional Health Services Director. R1 displayed no adverse reactions but was sent to the hospital for evaluation as a precaution. R1 returned the same day with no new orders. The primary physician and R1’s family were notified of the incident.

In response, all medication technicians received credentialed training from the Allen Flores Group on April 8 and 9, 2025.