complaint·February 23, 2024

Based on interviews with Nurse Mel Dearing and Omnicare account Manager it was informed to LPA Lee that some resident’s medications, the doctors doesn't justify the specific time of when the medication is to be given to resident. Medications only states once a day, twice a day or 3 times a day. Residents’ medications were given at 8:00 AM if residents medication states once a day. Residents’ medications are given to residents at 8:00 AM and 5:00 PM if residents are to take their medications twice a day. If residents’ medications indicate three times a day, then resident’s medication are given to resident at 8:00 AM, 12:00 PM and 5:00 PM. Based on interviews with Omnicare, it was learned that usually the provider will send residents order to the facility and then the facility will send the order to Omnicare and Omnicare will enter the order and push the order through into PCC which will generate residents medication list for the facility. Based on records review 10 out of 10 residents’ routine medications were in both Quick Mars and PCC. Upon reviewing residents PRN medications in Quick Mars and PCC there were discrepancies due to the transition of the two programs. It was learned that Omnicare was working with the facility in auditing residents’ medication. Moreover, some of the residents' PRN medications are either discontinued or are new orders that has not been entered into PCC. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. Allegation: Staff are improperly storing narcotics. It was alleged that Staff are improperly storing narcotics. This investigation consisted of observations, records reviewed, and interviews with facility staff. LPA Lee interviewed 4 out of 4 Med-techs who denied the allegations. On 01/17/2024 complaint visit LPA Lee asked to look at Med Chats 1, 2, and 3. LPA Lee did not observe resident 1 (R1) and (R2) narcotics in any Med Charts. LPA Lee also looked at other residents’ narcotics in the med chart 1, 2, and 3 and it was learned that narcotics in the med carts are for residents residing in the facility. During today’s visit, LPA Lee also requested to look at Med Chart 1, 2 and 3. LPA Lee observed narcotics stored in the med cart are for residents who are still residing at the facility as well. In addition, LPA Lee reviewed (R1) LIC 622 Medication Destruction Record and it was learned that (R1)’s narcotics was destroyed on 12/01/2023 on the day that (R1) was deceased. Continued LIC 9099-C LPA Lee also reviewed (R2) LIC 622 Medication Destruction Record and it was learned that (R2)’s narcotics was destroyed on 12/04/2024 on the day that (R2) was deceased. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.