complaint·October 25, 2024

On 07/18/2024 the Department interviewed Staff #1- Staff# 3 (S1-S3), and reviewed records of resident #1- resident #3 (R1-R3). On 07/18/2024 the Department interviewed witness #1 (W1). The Department requested to the following documents: the Medication Administration Records (MARs), physician's orders of prescriptions, progress notes, health assessments, and any documentation of changes in health condition and incident reports related to Resident #1- Resident #3 (R1-R3). The department requested any communication logs or records, facility's policies and procedures related to medication administration, and training records for S1-S3. Investigation Revealed the Following: Allegation: Staff did not administer resident's medication as prescribed It is alleged that on 7/8/2024 R1 did not receive their PRN medication. On 07/18/2024 the department interviewed Socorro Trinidad, facility administrator. The department asked if staff did not administer resident's medication as prescribed. The Administrator stated there were no concerns or issues with staff administering resident's medication as prescribed. On 07/18/2024 the department interviewed staff #1- staff #3 (S1-S3) who were asked if staff did not administer resident's medication as prescribed. Of those interviewed S1-S3 stated there were no concerns about staff administering resident's medication as prescribed. On 07/18/2024 the department interviewed witness #1 (W1), who was asked if staff did not administer resident's medication as prescribed. Witness #1 (W1) stated there were no concerns about staff administering resident's medication as prescribed. On 07/18/2024 and 10/22/2024 the department conducted reviews of facility records. Per physicians’ orders from Roze Hospice, R1 was prescribed Morphine Sulfate (Concentrate) to be administered orally at a dose of 5 MG every 4 hours as needed for severe pain or shortness of breath. On 07/18/2024 and 10/22/2024 the department reviewed facility notes, which state a discontinuation of previous medication orders for morphine to be started on 7/7/2024, orders given o the facility at 12:45pm and an accompanying prescription issued on 7/8/2024 written at 12:49PM. CONTINUE REPORT TO LIC9099C Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not administer resident's medication as prescribed. 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. Allegation: Staff did not inform the resident's authorized representatives of the resident's change in health condition On 07/18/2024 the department interviewed Socorro Trinidad, Administrator who was asked if staff did not inform the resident's authorized representatives of the resident's change in health condition. The Administrator stated there were no concerns or issues with staff not informing the resident's authorized representatives of the resident's change in health condition. On 07/18/2024 the department interviewed staff #1- staff #3 (S1-S3) who was asked if staff did not inform the resident's authorized representatives of the resident's change in health condition. Of those interviewed S1-S3 stated there were no concerns about staff did not informing the resident's authorized representatives of the resident's change in health condition. On 07/18/2024 the Department interviewed witness #1 (W1) who verified W1 is to be contacted for resident. W1 reported the facility staff provided updates and condition changes of resident’s condition to the authorized representative. On 10/22/2024 the department reviewed facility records and confirmed authorized representative for residents. Based on interviews and observations there is insufficient evidence to support the allegation: Staff did not inform the resident's authorized representatives of the resident's change in health condition. 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. There were deficiencies cited on today's visit. Exit interview conducted. A copy of the report was given to Socorro Trinidad, Administrator. .