Facility Evaluation Report

On 4/17/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management visit to follow-up on recent incident reports submitted to the regional office. LPA met with the nurse and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions. LPA complied with facilities masking policy.

On 4/13/23, the regional office received an incident report that stated that on 04/03/2023 at 5:50 am. Noc Medication care manager (S1)gave the a new resident (R1) levothyroxine 75 mcg. The resident has an order for levothyroxine 50 mcg, R1 received an additional 25 mcg. Resident (R1) self-manages R1's own medication. R1 suffered no ill effects as a result and R1's physician recommended continue with regular scheduled doses. S1 received an in-service regarding the medication errors.

The facility also submitted a incident report regarding a medication issue which occurred on 4/8/23 regarding PRN medication for R2 administered by S1. R2 had an original prescription for half a 5 mg dose of pain medication. During a follow-up visit R1's physician gave a verbal order for a full tab of the same medication. On 4/14/23, R1's physician provided a written order for a full tablet.

However, records review found that the facility was in possession of a hospital discharge summary stating a half tab be given for R1's pain on 4/8/23. This summary was not signed by the physician.