Complaint·April 7, 2022

Regarding Allegation #1 : this investigation revealed that the facility administered the medication (Xanax) to Resident #1 (R1) that was prescribed by one of the facility’s attending group physicians (neurologist). Reporting Party stated that it had not been communicated to Resident #1’s (R1’s) Responsible Person (RP) or Primary Care Physician (PCP), Dr. Elizabeth Whitman, MD. While visiting R1 at the facility on 02/01/2021, R1's RP was looking for a "new" neurologist for R1 due to the resident's multiple behaviors. R1's RP had approached ED/A1 James Arp in regards to the facility's attending group physicians (neurologists) who conduct evaluations on residents. ED/A1 brought R1's RP an application and consent form (with a list of physicians that also included R1’s PCP). ED/A1 introduced R1's RP to Dr. Yul Rapoport, MD (Neurologist); and, R1's RP approved of the Neurologist because the consent form was signed on 03/23/21. R1’s RP admitted to signing the consent (with the understanding that R1 is to continue seeing the PCP). R1’s RP later found out that one of the facility’s attending group physicians had prescribed the medication (Xanax) to R1 without consent. Staff #4 had discussed to R1's RP to administering R1's medication (Xanax) once; of which, there was no further discussion. LPA/RA Ceniceros inspected the facility’s Med Tech Room and observed the facility's computerized system for residents medication administration record. LPA/RA observed the medication (Xanax) was prescribed to R1 by Neurologist (Dr. Yul Rapoport, MD); and, discontinued by Primary Care Physician, Dr. Elizabeth Whitman, MD on 05/20/21. LPA/RA Ceniceros interviewed five (5) facility staff members (S1-S5) who indicated that R1's medication (Xanax) was administered to the resident - based on the physician's order on file (dated 05/14/21) once a day, as needed for multiple behaviors - until it was discontinued on 05/20/21. LPA/RA Ceniceros interviewed five (5) residents; and, the majority had not experienced an issue with the facility’s attending group physicians’ changing his/her medication or ED/A1 not consenting to his/her responsible person(s). Based on interviews, observations, evidence gathered, information and documentation obtained and reviewed, 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 of MEDICATION: Facility changed resident’s medication without consent is UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to Staff #1 Director of Resident Care Services, Ann Margaret Zavela; as the Executive Director/Administrator (James Arp) was unavailable at the time of this visit.