Complaint·May 12, 2022

On 05/12/2022, LPA Agard delivered findings. Regarding the allegation: Staff did not follow physician's orders for administration of medication(s). “It’s being alleged a person with needs, staying at the board and care home was either over medicated or undermedicated.” The investigation revealed the following: 2 out of 2 staff denied the allegation to be true. S1 states, “all the medication on the medication administration records was being given. Everything that was on the med sheet was given.” S2 states, “we have always given medications for R1 as prescribed. The private caregiver was using a medication that was not prescribed by Hospice and they wanted us to use that same medication without an order.” LPA was unable to conduct interviews with residents due to their cognitive abilities. During interviews with witnesses, W1 states being told medication was not being given as prescribed. “A late-night person at the facility told me and W3 that they were not giving R1 morning medication. W2 could not confirm the allegation to be true but cites: “I recall a conversation with S2 regarding issues with the medication. We provided the facility with a list of medications to give the patient but there are some cases where the family have their own preferences of medication which happened in this case. They will bring their own over the counter meds and creams that they want to use but we wouldn’t know about it.” W3 was unable to confirm or deny the allegation and W4 states never having an issue or concerns about medication with the facility. LPA Agard reviewed the medication administration records (MAR) which indicate R1’s medication was given as prescribed. LPA was unable to verify which medication was allegedly being overmedicated or undermedicated by reporting party. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was given