Evidence/Findings:
Based on record review, observation, and interview, the manager failed to ensure a written order verifying the verbal order was obtained from the medical practitioner within 14 calendar days after receipt of the verbal order, for one of two residents reviewed. The deficient practice posed a health risk to the resident.
Findings include:
1. Review of R2's medical record revealed a current written service plan dated March 7, 2023. This service plan indicated R2 received medication administration.
2. Review of R2's medical record revealed a verbal medication order dated March 27, 2023. This order stated "Aspirin chew 81mg chew 1 tab QOD PO". However, documentation was not available showing a written order was obtained from the medical practitioner within 14 days.
3. Review of R2's medical record revealed a May 2023 medication administration record (MAR). This MAR stated "Aspirin Chew 81mg 1T PO QOD" and indicated one chew was administered at 8am May 1st - present.
4. During an observation of R2's medications, Aspirin 81mg was observed.
5. During an interview, E1 reported the medication was administered per the verbal medication order and acknowledged R2's medical record did not include a written order from the medical practitioner within 14 days.
Summary:
No deficiencies were found during the on-site compliance inspection conducted on June 30, 2025.