complaint·June 21, 2022

During the investigation process, the administrator, physician, resident and five staff persons were interviewed. In addition, documents were obtained to include Physician’s report, physician’s orders, medication log, admission agreement, texting communication and physician’s communication. It was reported that a resident (Resident 1) provided the facility nurse with a medication change order from a neurologist. The medication change order did not come from the neurologist; however, came from the resident. The nurse was not comfortable with the order change due to the amount of medication increase. The nurse contacted the resident’s General Practitioner (GP) physician, as the nurse could not get a hold of the neurologist, because it was late in the day. The GP advised the nurse to not increase the resident’s medication until there was verification from the neurologist of the medication change. During the investigation, the resident’s GP was contacted, and he confirmed that he told the nurse to hold the medication until the neurologist could confirm the medication change. During the time of the incident, the resident reported that he was physically not feeling well and the resident had the staff person contact emergency services to be taken to the hospital. Once the resident was at the hospital, he was able to see his neurologist and the neurologist made the appropriate medication change. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated