Olivia Restorative Care Center

During an interview on 8/20/25 at 9:35 a.m., LPN-C stated she had double checked R11'd admission orders and did not see the medication errors.

During an interview on 8/19/25 at 5:35 p.m., NP-A was made aware of these medication errors during his visit add today (8/19/25) DON. He reviewed R11's the medication list with the director of nursing (DON) for accuracy and changed to medications to read as per physician hospital discharge orders dated 8/15/25. NP-A stated R11 was to have dialysis the following day and they would check his lab for calcium and phosphate levels as R10 did not receive the correct amount of calcium acetate for 8 doses. NP-A further stated it was his expectation that staff transcribed and verify medication orders as written by physician and if questions contact NP-A or MD for clarification.Review of facility undated procedure titled MD order process was reviewed and identified the following: 2. enter order with diagnoses/indication in electronic health record10.

Sign and date order11.

Put in SECOND CHECK BOX for second nurse to double check14.

Second nurse signs and dates order15. put in scan bin for health unit coordinator.

Review of facility undated policy titled Medication Orders indicated the following:3.

Elements of the medication order:b. name of medication, c. dose of medicatione. time or frequency of administrationg. route of administrationi. hour of administration 4.

Documentation of Medication Orders:a. each medication order should be documented with the date, time, and signature of the person receiving the order.

The order should be recorded on the physician order sheet, and the medication administration record (MAR).b. clarify the orderf. transcribe newly prescribed medications on the MAR, ensure the order is in the electronic MAR correctly.

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