complaint·January 2, 2025

On the allegation, "Staff mismanaged resident medication,"; it is the concern of the reporting party that a resident that lived at the facility long ago, received the wrong medication and almost went into cardiac arrest. No dates and/or other information about the alleged incident were provided. The LPA was unable to determine the resident. However, during a medication audit conducted for two (2) out of five (5) residents’ during today’s visit, the LPA observed the following. During Resident 1 (R1’s) medication audit, the LPA observed that R1’s Gabapentin is prescribed to be give one capsule by mouth two times a day, however the medication bottle was documented on the Centrally Stored and Destruction Record (CSDR) as two capsules being given once a day, and the medication bottle only had an evening sticker placed on the cap of the bottle. Upon observation, staff called the Administrator, and the Administrator explained to the LPA that when the resident arrived at the facility, they were getting two capsules once a day at their previous home and continue to do so at the facility. Additionally, R1’s Melatonin and Vit D2 were counted and had one more pill than they should have based on the date started documented on the CSDR. Upon observation, the Administrator stated that they did not know why the count was off, and when discussing R1’s Vit D2 1.25 MG medication that should be given once a week every Friday and should only have two left but have three pills left, they stated that they probably did not give them one last week. Based on the information obtained, although there is not sufficient evidence to support a resident went into cardiac arrest due to being given the wrong medication, medication audit revealed that R1 did not received Gabapentin as prescribed and did not receive their Melatonin and Vit D2 medication on one occasion. Therefore, the allegation of “Staff mismanaged resident medication” is deemed substantiated at this time. Exit interview conducted, deficiency cited, and the report and appeal rights emailed to the licensee.