| 6400.18(b)(2) | Clonazepam 2 mg; take one tablet by mouth twice daily for anxiety prescribed to Individual #1 was not administered at 4:00PM from July 5, 2019 through July 9, 2019. As of December 4, 2019, the medication error was not reported in the Enterprise Incident Management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Staff are required to complete a medication error form including for medication that is not available from the pharmacy. The forms are required to be faxed to the Wellness Coordinator by the end of the shift when the med error is discovered. Incident Manager will review all medication errors daily to ensure they are entered into the EIM system. [The medication error was entered in to EIM on 12/26/19. Three staff persons were educated on Incident management, reporting and documenting medication errors on 12/5/19, 12/11/19 and 12/18/19. Within 30 days of receipt of the plan of correction, upon hire and continuing at least annually, the CEO or designee shall educate all staff person on their responsibilities to ensure incidents, alleged incidents and suspected incident are reported through the Department's information management system, timely. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 12/26/19)] |
12/18/2019
| Implemented |