Frances Residential Care Home #2

Based on record review and interview the manager failed to ensure a resident had a written service plan signed by the nurse or medical practitioner who reviewed the service plan when initially developed, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan dated May 7, 2023, for personal care services including medication administration. However, the service plan was not signed by a nurse or medical practitioner. 2. During an interview, E1 acknowledged R2's service plan had not been signed by a nurse or medical practioner.

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 sampled. Findings include: 1. A review of R2's medical record revealed a service plan, dated May 7, 2023, for personal care services including medication administration. 2. A review of R2's medical record revealed an order dated June 8, 2023. This medication order included: - "Clonazepam 1 mg tablet, Take 0.5 tablets by mouth twice a day. Max daily Amount 1 mg. Oral." 3. A review of R2's medical record revealed a Medication Administration Record (MAR) dated June 2023. The MAR included the following medication, "Clonazepam 1 mg P.O. BID." The MAR indicated 1 milligram of Clonazepam had been administered to R2 at 8 AM and at 8 PM on June 8 at 8 PM through June 15 at 8 AM. 4. The Compliance Officer observed a mediset containing R2's medications included a 1 milligram Clonazepam tablet in each filled AM and PM section. 5. The Compliance Officer observed a bottle of R2's medications was labeled, "Clonazepam 1 MG tablet, Take 1/2 tablets by mouth twice a day." 6. In an interview, E1 reported R2's nurse had told the facility the dosage of Clonazepam would be increased to 1 milligram, however, E1 acknowledged the written order was for 0.5 milligrams and a verbal order was not available for review.