Torbrook Manor II

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order. Findings include: 1. A review of R2's medical record revealed a service plan dated January 14, 2025, which included medication administration. 2. A review of R2's medical record revealed a signed medication order dated February 10, 2025, which included Diazepam 2 Milligram (MG) PO (by mouth) once nightly PRN (as needed) [for] agitation. 3. A review of R2's medical record revealed a medication administration record (MAR) for February 2025. The MAR revealed that "Diazepam 2 MG PO QHS PRN Agitation" was administered on February 12, 2025; however, the time of administration was not noted because the heading of the administration time log was "PRN." 4. A review of R3's medical record revealed a Progress Note dated February 12, 2025 @ 3:20pm, which stated, "...[R2] asked if [E2] can help [R2] with a valium for agitation because [R2] said 'This is not life.' [E2] told [R2] that [E2] had a valium pill that was scheduled for tonight but [E2] could give it to [R2] now and [R2] was happy about it." 5. Further review of R2's medical record revealed five pages of progress notes along with three other notebook pages of the ongoing interactions with R2, particularly the noted incidents of ongoing agitation and requests for help or comfort from R2. The notes also included documentation of discussions with O1, which demonstrated O1's lack of cooperation with the facility's attempt to provide the best level of care and strategies for improvement with R2. 6. In an interview, E2 reported E2 told R2 E2 would give R2 the valium as R2 requested, but that R2 would not get it later in the evening, which R2 agreed to. E2 advised the medication order indicated the medication should be administered "nightly," but did not provide a specific time. E2 acknowledged administering the diazepam 2 MG pill to R2 on February 12, 2025 at approximately 3:30pm, and stated E2 will stand by E2's decision to administer the medication at the time E2 did as E2 firmly believed E2 was doing what was in the best interest of R2.