Complaint·September 16, 2024

The Administrator reported the facility wanted one on one care for the safety of R1 and the other residents and staff. The hospital social worker, physician and R1's family members did not think one on one care was required. At issue was the hospital's use of Haloperidol lactate injections of 2 mg as needed for delirium. The Administrator reported that she provided a new care plan for R1 to R1's family members but they did not agree to the new care plan. The Administrator reported that after the conference call she was provided with a new physician's report. A review of the physician's reported provided at move in and the one completed at the hospital showed two differences. The new physician's report (dated September 4, 2024) lists R1 as able to dress/groom self and the one provided at move in (dated March 31, 2023) lists R1 is not able to dress/groom self. The physician reported dated March 31 lists R1 as able to administer their own medication and the physician reported dated September 4 lists R1 as not being able to administer their own medication. Neither physician's report lists Haloperidol Lactate 2 mg as a regular medication. The Administrator reported that their concern was the use of Haloperidol Lactate and why was it not being continued if it was being used for the resident at the hospital. R1's family members reported that the physician reported it was no longer necessary and R1 did not require one on one care. On September 10, 2024 R1's family members went to the facility and gathered R1's belongings and informed the Administrator that they have relocated R1. The Administrator reported that they refunded R1's family members for September 2024. A review of records shows R1's family members signed for R1's belongings and for the refund check for $1398.00. R1 was agitated and in distress and needed medical assistance so they were taken to the hospital on August 30, 2024. R1 was treated and the hospital was ready to discharge R1. The facility wanted R1 assessed prior to discharge. The Administrator assessed R1 on September 5, 2024 and sent a revised care plan to R1's family members. A conference call was conducted on September 6, 2024 with all parties regarding R1 returning to the facility and their plan of care. No eviction notice was provided to R1's family members. No action was taken until September 10, 2024 when R1's family members removed R1's belongings from the facility and reported to the Administrator R1 has been relocated. The facility reported they would take R1 back if the the physician's report stated that R1 did not required a one on care. The physician's report dated September 4, 2024 states R1 does not require one on one care. The facility did provide a new care plan but there is no medical documentation to show one on one care was needed. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. The investigation into the allegation, medication not being administered as prescribed, revealed the following. It was alleged that R1's was not given the proper amount of medication and that R1 was given medication after is was discontinued. A review of R1's medication administration record (MAR) for August 2024 shows that R1 did not receive 8 different medications on 10 different days. The Administrator reported that the blank spaces on the MAR are when R1 refused to take medication. There is no key on the MAR to indicate what is noted for a medication refusal. There is no indication on the MAR that R1 refused any medications. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. An exit interview was conducted and a copy of the report provided along with appeal rights. Based on the evidence gathered the allegations is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.