Incident investigation·May 4, 2023

On 05/04/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident to obtain information regarding an incident that occurred at the facility on 04/13/2023. LPA met with Executive Director (ED), May Tate, and explained the purpose of the visit. The Case Management visit is in response to a telephone call and incident report that was submitted to CCLD. The report indicates resident (R1) responsible party (RP) was present at the facility on 04/13/2023. RP notified the facility that R1 is going blind in left eye due to staff not giving eye drops to R1. RP indicated R1’s eye drops have not been refilled in a while. The facility conducted an internal investigation. The facility reviewed R1’s medication administration records (MAR) to see if staff had been signing off, checked medication cart to see how many eye drops are currently in use, and how many backups are left. Facility had contacted R1’s pharmacy and confirmed refill dates. Facility interviewed Med Techs and confirmed they have been giving eye drops to R1. The facility reported the incident to CCL and Local Long Term Care Ombudsman. According to facility, RP refilled all 4 eye drops and dropped them off to the facility on 04/18/2023. LPA Keosavang requested for R1’s physician’s report, doctor's orders for medications, medication list, and MAR for review. LPA conducted interviews with facility staff. The ED was advised that at this time possible follow-up telephone calls or visits are necessary for further investigation. At this time, deficiencies are not being cited. An exit interview conducted and report provided.