Complaint·September 28, 2023

Allegation: Staff dispensed the wrong medication to a resident while in care. Based on LPAs' medication audit conducted on 09/28/2023, the audit included comparing R1's Medication Administration Record (MAR) with R1's medications, medication start dates and physician’s orders. During LPAs' medication count, (1) staff med tech was present at all times. Based on the medication audit conducted, file review of R1's MAR revealed on September 4th and September 5th, PM med tech did not sign that medications were administered to residents in care. LPAs conducted a medication count with S1 of R1's Glipizide. LPAs observed R1's physician order for Glipizide is to take two tablets by mouth two times a day 30 minutes before meals. LPAs observed bottle start date to be 8/31. During medication count, LPAs and S1 observed the Glipizide bottle of 120 tablets to have 11 tablets remaining, which means 109 tablets has been dispensed. Based on the signatures and/or initials on the R1's August 2023 and September 2023, total medication signed off totaled to 108 tablets, two tablets on AM shift of August 31, 2023 and 106 tablets month of September 2023. LPAs and S1 observed one tablet to be missing from R1's medication bottle and not accounted for. Based on the allegation, staff dispensed the wrong medication to a resident while in care , the allegation is SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following allegation cited above is substantiated, please see LIC9099-D. Exit interview conducted, copy of report and appeal rights was provided to Administrator.