Complaint·February 3, 2023

According to complainant, caregivers from Bright Star agency forced R1 to take medication against R1’s will. The Department reviewed R1’s physician’s report which indicated R1 ‘s primary diagnosis is Alzheimer’s disease. R1 is able to administer own medication and able to administer own PRN medication when handed directly to R1. An unusual incident/injury report was submitted to CCL for review. Incident report indicated a registry Med Tech notified the facility that two other registry staff were assisting Med Tech with providing medication to R1 in the evening of 10/25/2022. According to Med Tech, the two staff were assisting R1 and the Med Tech was inappropriate. The Department requested and reviewed written statement from two (2) registry staff provided by Bright Star Agency. Written statement from S1 indicated R1 refused to take medication twice. S1 assisted by holding R1’s face and S2 held on R1’s shoulders. Written statement from S2 indicated, S2 gently held on to R1's shoulders while S1 got R1 to open her mouth. S2 denied restraining resident. Interview statement gathered from S1 indicated, S1 had put her hand under R1's chin and S2 hands were on R1's forehands. S1 stated R1 did not fully take the medication only a portion of it. S1 indicated if a resident refuses to take medication sometimes staff would just put "medication with apple sauce." Interview statement gathered from S2 indicated, S2 suggested for Med Tech to indicate on R1’s Medication Administrator Records (MAR) that R1 refused, but Med Tech insisted that R1 needed to take medication for agitation to prevent R1 from lashing out at staff and other residents. S2 confirmed that S2 held on R1’s arms and shoulders while S1 was holding R1’s mouth. S2 indicated staff were partially success in providing medication to R1. The Department requested for S3's Med Tech credentials and medication training for review. The facility did not have records of S3's credentials or any medication training provided to S3. Due to this information CCL finds the allegation to be SUBSTANTIATED . – A finding that the complaint is substantiated means that the allegations is valid because the preponderance of the evidence standard has been met. Deficiencies are cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and a copy of the report left at the facility. The Department received and reviewed R1's physician's report. According to R1's physician's report, R1's primary diagnosis is Alzheimer's Disease. R1 is able to feed self. According to R1's assessment completed on 11/09/2022, R1 requires reminders for meals and eats independently with no meal adjustments. According to complainant, R1 was forced to eat against will. The Department interviewed and gathered statement from a total of five (5) facility staff. All five (5) facility staff denied witnessing or being involved in forcing R1 to eat against will. Interview statement received from R1 confirmed staff did not force R1 to eat against will. CCL finds the allegation to be 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, and the findings are unsubstantiated. Exit interview conducted. Copy of report provided.