Harmony River Living Center
HARMONY RIVER LIVING CENTER in HUTCHINSON, MN — inspection on October 15, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
rounding physician evaluated R1 on 9/16/25 and was reviewing the medication administration record (MAR) and identified R1 had missed twelve doses of Bumex.
The physician ordered labs and a dose of Bumex to be given when it arrived.
During an interview on 10/15/25 at 10:39 a.m., registered nurse care coordinator (RNCC) indicated he was not notified R1's Bumex was not available until 9/16/25. RNCC identified it was the TMA's responsibility to monitor the resident medication supply and reorder.
When a medication was not available the expectation was staff notify the pharmacy, notify the floor nurse and the floor nurse would follow up on it. If the medication was still not available, the floor nurse should be calling the RNCC on call.
RNCC further stated R1's hospitalization was due to the omission of the Bumex.
During an interview on 10/15/25 at 11:30 a.m., the director of nursing (DON) identified she was not aware of the significant medication error until R1's hospitalization on 9/16/25.
The DON also stated the facility had a protocol for an unavailable medication and it was not followed. It was the DON's expectation that TMA's and nurses follow the facility protocol.The following facility's corrective actions dated 9/20/25 were verified as implemented prior to the survey: -The facility completed a thorough investigation that identified the Medication Administration Policy was not followed and provided coaching and corrective action to staff involved.-Notified the medical director.- Conducted medication administration audits on all residents for medications marked unavailable and followed up on their findings.
Continued weekly audits. -Provided education to all staff on the facility Medication Administration Policy and Procedure with emphasis on directions to follow if a resident medication is unavailable.
Also, conducted random audits of staff knowledge of steps to take if a medication is not available.-Created laminated instruction cards for all medication carts. A facility policy, Medication Administration Policy last modified May 2021, identified it was the policy to ensure safe, effective, and timely drug therapy, to provide for an accurate and concise documentation system. RN's LPN's and TMAs would administer medication as ordered by the attending physician/NP (nurse practitioner).
Medications will be prepared and administered as near the scheduled times as possible. If a medication is not available, the emergency kit may be used according to policy.The facility Medication Administration Error Policy last modified May 2021, defined a significant medication error as on which causes the resident discomfort or jeopardizes his or health or safety. A medication error occurs when a prescribed medication is not available to be administered. If the above errors occur, the following action is taken: the employee who discovers the error must assess resident for any adverse effect and if needed contact emergency services; notify provider (MD/NP); notify the charge nurse, clinical administrator and or on-call nurse; notify resident representative; document in medical record.
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