Complaint·January 25, 2024

LIC 9099-C... Allegation: Staff mishandled resident's medication. Based on the file review of R1's January 2024 MAR, it revealed R1 is to take Eliquis 5mg tablet, twice a day. January 2024 MAR revealed the prescribed medication was signed for on January 20: AM and PM, January 21: AM and PM, January 22: AM and PM, January 23: AM and PM, January 24: AM and PM and January 25: AM. R1's MAR revealed Eliquis was given six (6) times during AM shift, starting January 20. R1's MAR revealed Eliquis was given five (5) times during PM shift, starting January 20. Based on LPA and Regional Nurse medication audit, it revealed R1's AM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed four (4) tablets to be missing from the AM packet, instead of 6 as documented on R1's MAR. Based on LPA and Regional Nurse medication audit, it revealed R1's PM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed three (3) tablets to be missing from the PM packet, instead of 5 as documented on R1's MAR. Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Magox 400mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Magox was given 5 times, starting January 21. Based on LPA and Regional Nurse medication audit, it revealed R2's Magox 400 mg medication bottle's start date was labeled as January 21, 2024. Based on the medication count, LPA and Regional Nurse counted 96 pills present in the bottle out of 100 tablets, meaning 4 tablets to be missing, instead of 5 as documented on R2's MAR. Please continue the report on LIC 9099-C2... LIC 9099-C2... Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Januvia 25mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Januvia was given 5 times, starting January 21. Based on LPA and Regional Nurse medication audit, it revealed R2's Januvia 25mg medication bottle's start date was labeled as January 21, 2024. Based on the medication count, LPA and Regional Nurse counted 26 pills present in the bottle out of 30 tablets, meaning 4 tablets to be missing, instead of 5 as documented on R2's MAR. Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Plavix (Clopidogrel) 75mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 12, January 13, January 14, January 15, January 16, January 17, January 18, January 19, January 20, January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Plavix (Clopidogrel) was given 14 times, starting January 12. Based on LPA and Regional Nurse medication audit, it revealed R2's Plavix (Clopidogrel) 75mg medication bottle's start date was labeled as January 12, 2024. Based on the medication count, LPA counted 91 pills whereas Regional Nurse counted 90 pills present in the bottle out of 100 tablets, meaning approximately 10 or 11 tablets to be missing, instead of 14 as documented on R2's MAR. When asked if recount is needed, Regional Nurse stated "90, 91 is close, but there is supposed to be 86 (tablets) in here". Based on the allegation, staff mishandled resident's medication , 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, and a copy of the report and appeal rights was provided.