Incident investigation·October 30, 2024

Licensing Program Analyst (LPA)/ Yolanda Rosser conducted a case management visit to follow-up on an incident report dated 5/8/24. LPA Rosser met with Administrator/ Chanel Ann Sanchez and explained the purpose of today's visit. The incident report was regarding 50 missing Oxycodone 325 mg tablets belonging to Resident #1 (R1) and subsequent police visit regarding the missing medication. LPA Rosser interviewed the Administrator/ Chanel Ann Sanchez, LVN/ Shirley Gonzalez, and Resident #1 (R1). LPA Rosser obtained copies of R1's facility file, medication administration Records for April 2024-June 2024, narcotic count audit forms, police incident report number, and Medical-Technician training verification. LPA Rosser found R#1 handles all medical and ordering medications independently. LPA found R#1 places orders for a surplus for Oxycodone 325 mg. The facility stores R#1’s medication and administered medications to R#1 who experiences a chronic pain condition. LPA Rosser found the facility conducts medication audits during shift changes as a measure to safeguard medication. The audits are conducted by the incoming Medical Technician and outgoing Medical-Technician at the end of shifts. The audits did not include the surplus medications as they are not administered until a depletion of medication occurs. On 5/7/24, a medication audit of surplus medication occurred, and 50 Oxycodone 325 mg tablets were missing from R#1’s surplus and on 5/8/24 an audit was conducted, and 195 Oxycodone 325 mg tablets were missing from R#1’s surplus. On 5/9/24 law enforcement was notified of the missing tablets and visited the facility on 5/9/24. The police department recorded the incident and no follow-up occurred. LPA Rosser found the department did not receive an Unusual Incident Report was submitted for the 5/8/24 audit results and missing tablets. During this visit, LPA Rosser inspected the storage of medications and found medications are properly stored as well as inaccessible to Residents. LPA found Medication Administration Records utilized and completed. LPA found the facility has protocols in place to safeguard medications by conducting audits at the beginning and end of each shift. During this visit, LPA Rosser conducted an interview with R#1 who states they were informed of the missing tablets from their surplus medication on hand and missing medications reported to local law enforcement. R#1 stated the missing tablets did not interfere with their medication regimen. LPA Rosser conducted interviews with LVN/ Shirley Gonzalez and Administrator/ Chanel Ann Sanchez who stated they are unable to confirm how the medication went missing and Medical Technician training occurred after the incident. Additionally, the facility requested assistance from the corporate Registered Nurse to evaluate the system of medication facilities administration and make recommendations that are now employed as additional measures to safeguard medication. LPA interviewed LVN, Shirley Gonzalez who indicated that she contacted the pharmacy and R#1 physician to report the missing medication, R#1 had surplus medications on hand. At this time no citations have been issued and an exit interview was conducted with the Administrator. The Administrator was provided a copy of this report.