Observations
Based on a review of client records, the facility failed to record medication errors in the client record in three out of seven records reviewed.
Client #1 was admitted on September 9, 2025 and was discharged October 21, 2025. Client #1 was prescribed Lisinopril and Sertraline one time a day; however, there is no documentation that the client received Lisinopril on September 24, 2025, or that the client received Sertraline on October 10, 2025.
Client #2 was admitted on July 22, 2025 and was discharged September 29, 2025. Client #2 was prescribed Mirtazapine and Prazosin daily at nighttime; however, there is no documentation that this client received this medication on August 2, 2025, August 3, 2025, August 14, 2025, August 18, 2025, August 19, 2025, or August 27, 2025. Additionally, this client was prescribed Sertraline one time a day; however, there is no documentation that Client #2 received the medication on September 11, 2025, September 12, 2025, or September 13, 2025
Client #3 was admitted on June 12, 2025 and was discharged on October 10, 2025. Client #3 was prescribed Buspirone two times a day; however, there is no documentation that the client received the medication a second time on August 31, 2025, or both doses on October 9, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from January 2, 2025, licensing inspection.
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Plan of Correction
A staff meeting was held on 02/13/2026 to review the findings of our DDAP inspection held on 02/11/2026. During this meeting, our policy on medication relating to 709.32 was reviewed. The policy states the following procedure for monitoring the client's self-administration of approved medication will be adhered to by Clem-Mar House staff:
1. At their designated times, each client will report to the medication room. Residents are handed their medication, one at a time, and with review their medication instruction. Staff verifies that the appropriate amount was administered by the client before consumption. The client then replaces the cap on the bottle and returns bottle or bubble pack to the staff member who puts it in the medication cabinet. The Medication log is then initial by staff and resident. This procedure is done for each medication at each designated time.
2. One staff member on duty, per shift, is authorized to remove medication from the medication cabinet.
3. Medication Logs are to be completed each medication pass and may not contain blank spaces. When a resident leaves, the log is dated with their date of discharge and blank spaces are crossed out, with staff initials.
As stated in the aforementioned policy, all medication adherence is documented at each med pass. A '0' is placed of the client is out of medication and a 'M' if the medication was missed. If a client misses, it will be documented in their chart additionally with a case consult completed by their primary counselor effective immediately.
If a client refuses their medication, a Medication Refusal Notice will be completed at that time, signed by both parties, as well as the Primary Counselor. This will be reviewed by the Counselor, and they will provide service recommendations, it will then be placed in the Client's chart to maintain consistent documentation.
The Project Director and Head Resident Manager will complete weekly inspections of the medication logs to ensure compliance.
The Project Director and Clinical Team Lead will complete monthly QA of charts to ensure compliance with documentation. |