Observations
Based on a review of the policy and procedures manual during a complaint investigation conducted on March 21, 2024, the facility failed to implement the written policy and procedures regarding all medications used by clients.
The medication errors procedures include documenting the errors on a Medication Incident/Error Report. Per the procedures, this report is to be kept on file in the Medical/Nursing office.
Documentation of a medication error that occurred at the facility, on a Medication Incident /Error Report, was missing.
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Plan of Correction
The facility/project director will train nurse C.G. on internal incident reporting protocol and DDAP incident reporting by Tuesday, 4/16/24. We will document this training with her. We have already informed her employer regarding this issue.
The facility director will audit the MAR on a weekly basis until these issues are resolved. If the facility director is unable to conduct this audit, they will appoint a substitute.
This process will be added to the agency's policy and procedure manual. |