moderate“people had not always received their medicines as prescribed. Staff were not always open when mistakes were made.”
moderate“where medicines had to be administered in a specific way and time, there was no detail on the medicines administration record (MAR) about when and how to do this.”
minor“where staff had redone their medicines competencies, there was no record of what staff had learned from their mistakes.”
missed or late visits
1 finding
minor“Some people however had care call visits that were not as evenly spaced as planned.”
incident learning
1 finding
moderate“healthcare professional advice had been sought, albeit several days later when the errors were identified.”