SUNCREEK 2 ASSISTED LIVING LLC

Based on record review, observation, and interview, the manager failed to ensure a resident's medical record included the correct strength for a medication administered to one of two residents reviewed. The deficient practice posed a risk as medication administration could not be verified against a medication order.

Findings include:

1. Review of R2's medical record revealed a current written service plan dated October 28, 2022. This service plan indicated R2 received medication administration.

2. Review of R2's medical record revealed a signed medication order dated January 18, 2023. This medication order stated "Acetaminophen 325mg tablet - take 1-2 tablets PO every 6 hrs for pain or fever".

3. Review of R2's medical record revealed a March 2023 medication administration record (MAR). This MAR stated "Acetaminophen 500mg tab take 1 tab po every 6 hours pain or fever as needed" and indicated Acetaminophen 500mg was administered on March 11th and 15th.

4. During an observation of R2's medications, Acetaminophen 325mg was observed.

5. During an interview, E1 reported two tabs of Acetaminophen 325mg were administered on March 11th and 15th per the medication order and acknowledged R2's MAR did not include the correct strength of the administered medication.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated February 12, 2023. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a signed medication order dated January 9, 2023. This medication order stated "Trazodone 300mg tab - take 2 tabs by mouth daily at bedtime".

3. Review of R1's medical record revealed a March 2023 medication administration record (MAR). This MAR stated "Trazodone 150mg tab take 2 (300mg) tabs by mouth daily at bedtime" and indicated 2 tabs were administered at 7pm March 1st - present.

4. During an observation of R1's medications, Trazodone 150mg was observed and 2 tabs were observed prefilled in the "Bed" slot of R1's medication organizer.

5. During an interview, E1 reported Trazodone was administered per the MAR and acknowledged R1's medication was not administered in compliance with the available medication order.