Complaint·April 26, 2021

Documents reviewed revealed, facility staff did not administer R1’s medication per physician’s order on 1/3/2020, 1/13/2020, 1/18/2020, 1/25/2020, and 2/8/2020. LPA interviewed and received statements from five (5) facility staff (S). Interview with S4, indicated that if there are no facility staff signatures on the MAR’s then most likely the medication was not given to the resident. Medication notes was provided by facility for review. LPA reviewed medication notes and observed on the dates listed above, there are no notations or explanation to why medication was not given to R1. Facility was unable to provide documentation stating R1 had refused their medications. LPA requested for facility’s sign in and out sheet for the month January of 2020. Document reviewed revealed, R1 did not sign out of the community on the dates listed above. Per Facility’s Medication Policy, missed/refused medication are documented in the resident’s medication record and in resident’s care notes. The prescribing physician is notified or missed/refused medications immediately or in the time frame and according to the parameters as indicated by the physician using the Refusal of Medication Notification form. Physician parameters must be retained in writing and filed in the chart under Physician Orders. The responsible party is notified. The Resident Care Director re-appraises the resident and contacts the physician and responsible party if the resident is continually refusing a medication(s). LPA requested for facility’s communication with R1’s Physician to notify them of missed medication per facility’s policy. Facility was unable to provide documentation for the month of January and February of 2020. Allegation: Staff did not inform authorized representative to renew physician’s order. – Substantiated. On 10/05/2020, LPA Keosavang and Leitzell was present at the facility to conduct interviews with facility staff and residents. LPA reviewed five resident’s files. LPAs observed that there was not a notice to resident’s (R1) authorized representative regarding renew Physician’s order for medication and blood pressure orders. Per Physician’s Order, R1 needs to take a medication that requires facility staff to monitor R1’s blood pressure to determine the amount of dosage that needs to be given. The end date in R1’s MAR for the medication was dated on 2/8/2020. After 2/8/2020, there were no communication with pharmacy, R1’s Doctor’s office, and R1’s authorized representative for new orders. LPA requested for facility’s communication with R1’s Physician and pharmacy. Facility is unable to provide documentation. ******* Continue on LIC9099-C ************ LPAs interviewed and received a statement from prior Executive Director, Jasmine Ridenour. Interview with Jasmine Ridenour revealed that the facility does not usually contact the resident’s authorized representative regarding blood pressure orders because family is usually involved in R1’s wellbeing. Jasmine Ridenour stated they did not contact resident’s authorized representative of change in Physician’s order to conduct blood pressure monitoring. Due to this information CCL finds the allegation to be SUBSTANTIATED . – A finding that the complaint is substantiated means that the allegation 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 will be sent via email to Executive Director, Debra Duval, and a signed copy is to be returned to LPA.