Complaint·April 9, 2024

(Continued from LIC9099) Administrator could not stay to sign todays report and designated Hermon Ledesma, staff to sign. Allegation: Staff did not administer medication to resident while in care. It is alleged facility failed to provide medication during the time R1 was discharged from Hospice. To investigate this allegation on 05/17/2022 LPAs Joscelyn Martinez and Tuesday Cabiness conduct an the initial complaint visit. Review of Medication Administration Records (MAR) on 05/17/2022 for the time period in question revealed medication listed on MAR was checked off as being provided after Hospice discharge date of 10/14/2021 to 12/16/2021 but not checked off as being provided from 12/17/2021 to 12/31/2021. Facility is not able to provide MAR or Centrally Stored Medication or Destruction Records for the first week of January 2022 before R1 was sent to the hospital. LPA Martinez notes Medication documentation picks up again on February 2022. On 05/17/2022 LPAs Martinez and Cabiness conducted interviews with four (4) out of four (4) residents and on 03/18/2024, LPA Rios conducted interviews with 4 out 4 residents. Resident interviews revealed they cannot recall experiencing missed medication, or medication errors. According to interview on 03/18/2024 with staff responsible for assisting residents with medication they deny the allegation and they state they have always provided medication as directed. Interview with staff on 04/09/2024 revealed they cannot recall why MAR was not filled in for 12/17/2021 to 12/31/2021, but they are certain medication was provided. Interview on 05/17/2022 with staff revealed that during that time they forgot to fill MARs for the month of January 2022. On 04/03/2024 LPA Rios conducted an interview with a representative from R1's former hospice agency that revealed, Hospice handled prescribing and making sure medications were filled by Hospice pharmacy for R1. Furthermore, Hospice agency representative revealed they would have provided at most a 2 to 4 weeks supply of medication after discharge date of 10/14/2021, while R1 made an appointment with primary doctor. Interview with administrator on 03/18/2024 and again on 04/09/2024 still denies the allegation and they state medication has always been provided. Review of records on 04/09/2024 revealed, facility kept medication administration records (MAR) for December 2021 to document medication assistance. MAR for residents during the month of December 2021, revealed resident #2 (R2) unlike resident #1 (R1) was not missing recorded days of medication for 12/17/2021 to 12/17/2021. Indicating facility failed to properly record medication administration for R1. Based on facilities own MAR documentation showing the discrepancy between R1 and R2 and the facility unable to provided documentation for R1 showing medication was filled by a pharmacy or a medication list provided by a doctor for time period 12/17/2021 to 01/06/2021 the determination for allegation; staff did not administer medication to resident while in care is Substantiated. Deficiency cited (refer to LIC9099D). Appeals discussed and provided. Copy of report provided.