complaint·July 9, 2024

Report is amended to include closing paragraph with findings for second allegation below. Staff over medicated resident. On the allegation that the ‘Staff over medicated resident’, it is the concern of the complainant that R1 was receiving unnecessary medications and that R1 appeared drugged, barely able to speak or eat as R1 appeared to be unable to hold bread or utensils, is unable to fully open their eyes, and is speaking gibberish. To investigate the allegation, the LPA reviewed the Centrally Stored Medication and Destruction Record (LIC 622) and compared against the list of medications ordered by R1’s physician. All medications listed in the LIC 622 and the physician’s orders matched. Additionally, the LPA conducted a medication audit of the medications (the quantity of pills) which matched the count as of the start date of assisting with the medications, and as listed in the LIC 622. The interview with R1’s responsible party (RP) revealed that the medications were prescribed by R1’s primary physician. The RP added that the physician was made aware of the reaction to a specific medication, and the physician removed the medication that may have caused the drowsiness. The LPA spoke with one of R1’s family members on 07/08/2024, and the family member stated that R1 was back to their normal self and no longer appeared confused or drugged. Based on the information gathered through interviews and record review, the allegation of Staff over medicated resident, is deemed Unsubstantiated at this time. Staff did not ensure facility phone was answered. On the allegation that ‘Staff did not ensure facility phone was answered’, it is the concern of the complainant that they attempted to reach staff at the facility, and tried three different times but was unable to get through. Complainant was hung up on during one of the calls. To investigate the allegation, LPA Urena interviewed staff(S1), regarding the facility staff not answering the phone, S1 stated that the phone is always answered. When the LPA asked why anyone would say that the phone was not answered, the S1 stated that often times the staff are busy caring for residents, changing the residents’ diapers, etc. and staff may not be able to answer the phone. The LPA called the phone number registered for the facility to test and see if the phone ring tone was loud enough to be heard by staff. The phone worked fine, and staff answered. The LPA interviewed the R1’s RP about the facility phone, and the RP stated that R1 cannot hold the phone or speak coherently, and they have never had a problem communicating with the facility and stated, ‘I am here with R1 at the facility almost every day, since R1 was admitted to the facility; I am happy with the care the caregivers are providing to R1’. Based on the information gathered through interviews and record review, the allegation of Staff did not ensure facility phone was answered’, is deemed Unsubstantiated at this time. LPA Urena emailed LIC9099 C to licensee to sign and return. Exit interview was conducted, and a copy of the report was issued.