Incident investigation·June 11, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection to follow up on an incident that occurred in May 2024. LPA met with Henry Cole, Administrator and stated the reason for the inspection. On 5/3/24, the Administrator notified the Department that (10) tablets from a supply of (30) tablets of PRN Norco 5/325 mg were discovered missing from the medication room, around 5:00 am earlier that day, for resident (R1). The Administrator immediately contacted a lock company to re-key the entire medication room and (2) ALU medication carts. An internal investigation was conducted and both Med-Techs (S1/S2) who worked on the NOC shift from 5/2/24 to 5/3/24, denied taking the medication and were given corrective action. LPA was provided with updated information during today's inspection that a staff member, who worked as both a Med-Tech and caregiver, possibly kept the key to the medication room during the shift they were scheduled as a caregiver, following the shift they worked as a Med-Tech. Staff are now required to sign in and out for keys at the start/end of a shift to ensure keys are only given to Med-Techs and also stay on site. The facility promptly notified all parties involved in (R1's) care and installed cameras in the medication room following the incident and there have been no additional medications missing. The Administrator and a Med-Tech staff confirmed (R1) would regularly request Norco 5/325 mg in the evening hours, around the start of NOC shift, for pain relief, and staff was still using the medication received in bubble packs and had not started the new bottle yet. Also, a new prescription for the pain medication, Methodone, written on 5/1/24, was to be administered twice daily. The medication did not run out and the resident received the new pain medication that had just been prescribed. A Technical Advisory note is being issued . Exit interview. Copy of report provided.