Complaint·May 11, 2023

Upon move-in, R1 was prescribed three medications. One medication, Trazadone, had an order that was routine and as needed (PRN). On 3/24/2023, R1’s primary physician wrote a discontinue order for the Trazadone. At the facility, the routine Trazadone was discontinued, however the PRN order maintained. LPA clarified with R1’s primary physician who stated that her discontinue order was for both routine and PRN. Additionally, the PRN Trazadone order stated to give ½ tablet (25mg) to 1 tablet (50mg) by mouth at bedtime as needed for insomnia. R1’s MAR shows that the PRN Trazadone was given 8 times in March and once in April. Furthermore, R1’s PRN authorization form stated, as filled out by R1’s physician, that ‘My patient cannot determine his/her need for prescription and/or nonprescription PRN medication and cannot communicate his/her symptoms indicating a need for a nonprescription medication’. This form continues to state that ‘If your patient cannot determine his/her need for a medication or clearly communicate the symptoms for a nonprescription medication, then you, the physician, must be contacted before the PRN medication can be given’. There was no documentation or communication produced that shows the facility contacted the physician prior to giving the PRN medication to R1. Based on the information detailed above, LPA finds that both these allegations are substantiated. A finding that the allegations are Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on 9099-D. Appeal rights were printed and given. Exit interview conducted. A copy of this report was left at the facility. R1’s chart notes that he would, at times, refuse medications. Staff interviewed stated that he would sometimes refuse assistance with activities of daily living (ADLs). Staff interviewed stated that R1 would become agitated and verbally combative. Staff interviewed stated that R1 was constantly walking in the hallways and common areas. All staff acknowledged that there were daily, repeated attempts during mealtimes, redirecting when exit seeking/wandering, and repeated attempts for ADLs. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. A copy of this report was provided to the facility.