complaint·October 30, 2023

Continued from 9099 LPA's medication audits revealed R1 did have a 7 day pill case stored with their medication , but it was observed to be empty at that time. The Medication Administration Records (MAR) indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Interviews revealed that staff did not recall specific occurrences where medication errors occurred. LPA's Interview with (4) four residents in care revealed they did not express any concerns as it related to receiving their medications. LPA's interview with seven (7) staff revealed they could not recall a time when a resident did not receive a medication due to error. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff mishandled a resident’s medication while in care has been deemed Unsubstantiated at this time. It was reported that Staff did not address a resident’s change in condition while in care, as it was alleged that facility staff did not report to R1’s home health nurse that R1 has not had a bowel movement for several days. Interviews conducted and records review revealed that R1’s home health nurse would visit R1 approximately twice a week and each time the home health nurse visited they were regularly notified about changes of condition in R1 by Staff #1 (S1) and Staff #2 (S2). Updates were also provided to the home health nurse via phone calls, emails and resident records kept at the facility. LPA records review of resident records from September 2021 to January 2022 revealed bowel movements were recorded and updated regularly during that time. Interviews conducted with seven (7) staff further revealed that if they observed a change of condition in any resident, they would notify the Administrator and notate their observations in the resident’s file. All (7) staff also indicated that when any home health nurse conducted visits, they would always update the nurse about their patient. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff did not address a resident’s change in condition while in case has been deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.