Complaint·June 24, 2021

There is an allegation unqualified staff administered injectable medications to resident . Staff interviewed described the various methods they use to assist resident with medications, including liquid medications from syringes. Administrator requires staff to take a medication quiz to confirm completion of medication training module. One of the questions on the quiz reflects, ”Which of the following should you do before assisting the resident with their medications.” Based on a review of staff training records, all staff who assist in the administration of medications have the required training per regulation. Based on LPA interviews, record review and observation 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 above allegation is UNSUBSTANTIATED. LPA obtained information regarding procedures of Coumadin Clinic at facility. The clinic would call the facility when they received the results and tell S1 or S2 over the phone what dosage instructions to follow prior to the next blood draw. The staff would write it on a post it note and set up the medication according to those directions. R1 would receive Coumadin dosage based on those directions until the next time the Coumadin Clinic would draw labs. The standing MD order and instructions on the medication bottle only stated "Coumadin 5mg- take as directed. Documentation revealed facility did not keep record of weekly dosage of Coumadin per physician/nurse advising after blood draw results reviewed. There is no evidence R1 had access to medications or medication was missing. This will be addressed in a case management. LPA attempted to contact treating physician for 10/15/2020 hospitalization on 4/5/2021, 4/13/2021, 4/28/2021, 5/26/2021 and 6/19/2021 to distinguish if cause of hospitalization was the result of overmedicating R1 or an accumulation of Coumadin in R1’s system. Medication Administrator Records (MARs) for October 2020 reflect Warfarin (Coumadin) 5mg take as directed. Kaiser Medication list indicates Warfarin (Coumadin) 5 mg oral tab Take as directed by Coumadin Clinic or physician. Order was effective as of 4/2/2020. Hospitalization documentation dated 10/15/2020 reflects a diagnosis of Anticoagulant Overdose, Accidental, init ICD-10-CM T45.511A. Documentation also reflects reason for transfusion -urgent reversal of Warfarin. Interview with outside party on 6/23/2021 indicated…in general it would be very difficult to determine from labs whether high lab values are due to an excessive dose of Coumadin versus accumulation. LPA asked about ICD 10 code. Outside party indicated the word "overdose" is not a term used in the medical field, it is a reference code. There are so many different contributing factors that affect lab values…LPA attempted to interview R1’s Primary Care Physician on 4/26/2021. Physician refused to give LPA any information regarding R1. Based on LPA interviews, record review and observation 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 above allegation is UNSUBSTANTIATED. (See LIC 9099-C)