complaint·September 7, 2023

Page 1 Staff do not give residents’ medication as prescribed - UNSUBSTANTIATED It was reported that medications are not being dispensed properly. LPA review of EMAR for Resident 1 (R1) revealed that R1 had been prescribed Quetiapine (Seroquel) 100 mg on 11/23/2020, 1.5 tablets were to be taken by mouth at bedtime. Also, on 11/23/2020 R1 was prescribed Quetiapine (Seroquel) 100 mg, 1 tablet to be taken in the morning. According to the EMAR both of these prescriptions were discontinued on 6/16/2023. On 6/16/2023 a new prescription for Quetiapine (Seroquel) 50 mg was started and dispensed 2 tablets once per evening. LPA reviewed physician’s orders for R1 for prescriptions for Quetiapine (Seroquel). 11/23/2020 Order summary: Quetiapine Fumarate Tablet 100 MG Give 1 tablet by mouth in the morning for agitation supervised self-administration AND Give 1.5 tablet by mouth at bedtime for agitation supervised self-administration. 06/16/2023 Order summary: Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate). Give 2 tablets by mouth in the evening for depression. 4 of 4 staff stated they use a computer with an EMAR to ensure they are dispensing the correct medication to the correct resident. They check the resident photo, name, and prescription before dispensing. Administrator stated the facility uses the point click care computer system which has the resident’s photo and bubble pack medications. Staff compares the order on the screen to the bubble pack and photograph and double check that they match. It was determined that the facility dispensed medications as prescribed by R1’s physician. Staff use the EMAR to ensure they are dispensing medications to residents properly. This allegation is unsubstantiated. Continued on LIC9099-C Page 2 Staff do not properly keep records of medication being distributed It was reported that medications are not being recorded properly. Staff interviews revealed that the computer system gives staff the option to click “No medication has been dispensed” or “Yes medication has been dispensed. “This information is saved in the computer system as soon as the resident takes the medication and logged in the resident’s EMAR. Administrator stated using the point click care system, staff click that the medication has been given, and the computer system will not let staff leave their shift until they have dispensed the medications. This allegation is unsubstantiated. Staff do not ensure the disposal of expired and/or discontinued medication - UNSUBSTANTIATED It was reported that medications are not being destroyed timely. During staff interviews it was learned that when a medication is discontinued staff are notified by the physician or pharmacy. Each resident has a profile in the computer system that has all of their orders and a list of discontinued medications. This is documented on each shift. When a medication is discontinued it is pulled from the med cart, recorded on the destroy record, and placed in a jug that contains a solution that destroys the medication. Two med techs are present during destruction of medications. Administrator stated the facility either gets a fax or communication from the resident’s doctor and that is faxed to the pharmacy . The facility then discontinues the medication in the computer, it is stamped and signed off and filed in the resident’s file. Two people dispose of medications and the facility has a disposal record. The resident services director and one other employee discontinues medications. The facility has a jug with drug destroyer solution which is used to destroy the medications. There is a form that is placed in the resident file that shows the medication has been discontinued. This allegation is unsubstantiated. Continued on LIC9099-C Page 3 Staff mismanage medication - UNSUBSTANTIATED This allegation is broad in scope and was investigated by LPA while conducting interviews and document reviews for the three aforementioned allegations on this same complaint, all of which concern the management of medications by the facility. This allegation in unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. An exit interview was conducted. A copy of the report was provided to Executive Director Sonya Gonzalez.