Follow-up on corrections·May 31, 2023

On 05/31/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to follow up on a Case Management- Incident visit conducted on 05/04/2023. LPA met with Executive Director (ED), May Tate, and explained the purpose of the visit. During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, medication administration records (MAR), receipt of medications, and medication list. The Department requested for R1’s physician’s report from the facility for review. The Department obtained an outdated physician’s report that was completed on 12/16/2021. According to physician’s report, R1 is diagnosed with Dementia and is unable to administer own prescription medications. On 04/27/2023, LPA Keosavang received an email from ED stating the facility was conducting an internal investigation on R1’s medication error. LPA and ED scheduled a telephone call to go over findings of the internal investigation on 04/28/2023. On 04/28/2023, ED stated R1’s MAR indicates that the facility are giving medications to R1, however, if the facility is giving R1 medication they should have refilled those medications by the dates they were supposed to be refilled, but per facility’s nurse, R1’s RP dropped off medications at the facility, but the facility do not have records of when the medications were dropped off and how many medications were dropped off. The Department received R1’s May 2022 through March 2023 MAR for review. According to R1’s MAR from May 2022 to July 2022, R1’s medications were given to R1. MAR for August of 2023 indicated, staff did not provide R1 Latanoprost on 08/07/2023 and 08/16/2023. On 09/25/2023, MAR indicates staff did not provide R1 Latanoprost. On 10/25/2023, MAR indicates staff did not provide R1 with Dorzolamide, Brimonidine, and Latanoprost. MAR for February of 2023 indicates all 4 medications were provided to R1. MAR for March of 2023 indicates staff did not provide R1 Dorzolamide, Brimonidine, and Rhopressa. MAR does not indicate a reason why medications were not provided to R1. According to R1’s responsible party (RP), there are four (4) medications that are not given to R1 per doctor’s orders. Medication for Dorzolamide last filled date was on 08/26/2022 with a 3-month supply duration. Refill fate for Dorzolamide was on 11/26/2022. Medication instruction is to instill1 drop in both eyes 2 times a day for Glaucoma. Medication for Brimonidine last filled date was on 05/24/2022 with a 3-month supply duration. Refill for Brimonidine was on 08/24/2022. Medication instruction is to instill 1 drop in both eyes 3 times a day for Glaucoma. Medication for Latanoprost last filled date was on 12/26/2022 with a 75-day supply duration. Refill for Brimonidine was on 03/11/2023. Medication instruction is to instill 1 drop in both eyes daily at bedtime for Glaucoma. Medication for Rhopressa last filled date was on 12/26/2022 with 25-day supply duration. Refill for Rhopressa was on 01/20/2023. Medication instruction is to instill 1 drop in both eyes once a day for Glaucoma. On 05/02/2023, an office meeting was conducted with R1’s RP to discuss medications concern. LPA Keosavang went over R1’s MAR and medication list with R1’s RP. R1’s RP provided LPA with boxes of the 4 medications listed above. RP stated RP was at the facility and had notified ED of concerns regarding medication not being given to R1. RP stated RP went over medication with the facility and observed medications to be full and unopened. RP took medications from the facility. RP stated if the facility is providing medications to R1 why are there boxes of unused medications. LPA confirmed the dates on the box of each medications matches the filled dates. LPA observed all 4 medications to be full and appears to not be given to R1. 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.