{"report_id":218,"form_id":"23","user_id":81,"organization_id":10,"question_id":"98","question_type":"Free_Text","text_answer":"Incident report description\r\nIndividual was discharged directly from the hospital to Meridian Kentucky, a Transition Home for adults.  Individual was prescribed Depakote 500 mg in the morning and 2000 mg in the evening every day for mood irritability per his discharge medication order.  Depakote was not put on the Medication Administration Record (MAR) at Meridian Kentucky as a daily medication, but as a PRN.  Due to not being on the MAR as a daily medication, the individual was not administered his medication for 8 administrations from 8\/9 to 8\/13.  The error was discovered mid-afternoon on 8\/13 and the Meridian LPN called and who recommended medication be started again at individual\u2019s night administration. \r\n\r\nDebriefing Information for Learning Point \r\nDebriefing date:\tNovember 18, 2019\r\nPerson debriefed:\tProgram Administrator\r\nMeridian staff, including the Program Manager of Kentucky went to the hospital to pick up individual to transport to Meridian Kentucky.  The Program Manager was given the individual\u2019s Medication Orders signed by a physician, a Discharge Summary and the individual\u2019s medication in prescription bottles.   At Meridian Kentucky, the Program Manager then completed the Medication Administration Record from the Discharge Summary which listed all the individual\u2019s prescribed medications.  The MAR\u2019s is used for staff to follow when administering the individual\u2019s medication.  Then a lead staff reviewed\/checked the MARS completed by the Program Manager for accuracy.  The lead staff signed off on the correctness of MARS.  \r\n\r\nThe Program Manager who completed the MARS no longer works for Meridian, not due to this incident but leaving state and was not available to be debriefed.  The Program Administrator (PA) of Meridian Kentucky was debriefed.  PA explained there are several checks and double checks documented in the process of completing a MARS.  The first was that when an individual is admitted directly from being discharged at hospital, that the actual signed Medication Order and the prescription bottles are to be reviewed to assure they match at the hospital.  Then the Program Manager should review the Medication Orders, and prescription bottles at the group home to again insure the match and then complete the MARS.  The PA stated that this was the first time the Program Manager had completed the MARS without supervision.  Then the process is the double checker, Lead Staff in this case, who was recently promoted and was her first time being a double checker, was to compare the signed order Medication Order, with the completed MARS, then compare the MARS to the created \u201cmedi-set\u201d of prescribed medications, then the completed medi-set back to the prescribed bottles. \r\n\r\nThe PA explained that the Program Manager was a newer employee to Meridian Services, had worked at this job for about 8 months, and again, it was the first time completing an intake and MARS independently.  The PA also stated the Program Manager developed the MARS with medication information from the Discharge Summary which also listed the prescribed medications.  The individual had an over the counter PRN listed on the Discharge Summary, and right below this PRN, Depakote was listed so it appeared it was also a PRN.  As stated previously, this was also the first time the Lead Staff, recently promoted, was responsible for double checking a MARS.  The Lead Staff noted the error around 4 days later.","created_by":81,"updated_by":81,"updated_at":"5\/25\/2021 10:26:52 am","created_at":"5\/25\/2021 10:26:52 am","id":16009}