complaint·April 18, 2024

Regarding the allegation: Staff mismanaged the resident's medication. The Investigation revealed the following: Regarding the allegation, “Staff mismanaged the resident’s medication”, it is being alleged Resident #1’s (R1) medication A (Haldol) was not discontinued. Medication Administration Record (MAR) revealed medication A was still being administered since R1 was admitted on 03/26/24. Interview with the Med Tech indicated that: on 03/26/2024, R1 was admitted to the facility from a skilled nursing facility with a medication list that included medication A; on 04/12/2024, R1’s Power of Attorney (POA) called the facility requesting medication A to be discontinued, but the facility refused since there wasn’t a doctor’s order; on 04/15/2024, the facility received a new prescription order from the R1’s doctor and pharmacy about discontinuing medication A . The department reviewed the MAR dated 03/26/2024 to 04/18/2024 and observed medication A was discontinued on 04/15/25. The department interviewed three staff #S members (S1-S3) and 3 out of 3 stated that they could not stop giving medications to residents unless it’s from a doctor’s order. The department interviewed seven residents #R (R1-R7) 6 out of 7 stated that they do not have any problem with the facility managing their medications. Based on interviews, and records reviewed the department did not find sufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. (Evaluation Report Continues LIC 9099-C) Allegation: #2 The staff did not administer medication as prescribed. Regarding the allegation: “The staff did not administer medication as prescribed,” it is alleged that the staff continued to give medication B (Zoloft) in the morning instead of the evening. Medication Administration Record (MAR) revealed that R1’s medication B is to be administered in the morning and staff distributed it in the morning. The department interviewed the Med Tech (MT) about the allegation, and MT denied the allegation and stated that (R1) was admitted to the facility on 03/26/2024 and R1’s medication B was administered per the physician’s directions on time, and the right doses. On 04/18/2024, the department reviewed seven residents' medication administration records (MARs) and 7 out of 7 records show that medication was given to the residents in the correct dosage and at the proper times. The department Interviewed the Licensed Vocational Nurse, (LVN) they denied the allegation and stated that we cannot stop giving or changing the time of administering (R1) medication because a family member or Power of Attorney (POA) wants us to. Based on interviews and records reviewed the department did not find sufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated (Evaluation Report Continues LIC 9099-C) No deficiencies cited. Exit interview conducted and a copy of this report was provided to Office Manager Shenick Jackson.