Survey date 2025-11-05 - inspection
22VAC40-73 standard 22VAC40-73-650-A: Based on documentation and record review, the facility did not ensure that no medication is started, changed, or discontinued by the facility without a valid order from a physician or other prescriber.
State agency did not assign a severity code.
Immediately after the med error was identified and reported: Medication cabinets audit at a 100% started and finalized on 10/3/2025. No discrepancies in orders or errors were identified. We will continue to monitor bi-weekly for three months. Education on medication administration and medication error prevention was completed on 10/1/2025 by RMAs involved in Resident #2's event. SDC and Wellness Manager performed medication pass observation with the three RMAs on 10/3, 10/6, and 10/7/2025 respectively. RMA's involved in a medication error had additional weekly medication pass observation the week of 10/14, 10/20, and 10/29/2025. One monthly med pass observation was conducted successfully in November, and another will be performed during December 2025. All other RMAs will complete training and med pass observation by 12/10/2025. Education to provider was provided on 12/5/2025 to include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug.
Corrected.