complaint·February 5, 2025

LIC 9099-C Allegation: Resident not receiving medication. The Department conducted extensive file reviews. Based on R1's e-MAR Order Administration Tracking report type of "Recorded As Given", it revealed that Levetiracetam 500 mg was prescribed to be taken one tablet by mouth, twice daily for seizure management. File review revealed on the date of 2nd, 5th, 6th, 14th, 17th, and 22nd of January 2024, only one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA did not observe any reasoning documented as to why resident did not receive medication. File review revealed on the date of 9th, 20th, and 29th of February 2024, only one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA observed only February 9th, 2024 to have a reasoning of " GIVE ON TIME" but no reasoning documented for February 20th and 29th, 2024. File review revealed on the date of 2nd of March 2024, no Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA did not observe any reasoning documented as to why resident did not receive medication. File review revealed on the date of 21st, 25th, and 26th of April 2024, one Levetiracetam tablet was administered for the day. File review of Order Administration Tracking report type of "Recorded As Drug Not Available" "Recorded As Drug Not Given" and "Recorded As OTHER", LPA observed "AWAITING REFILLS" and "waiting delivery" to be documented for April 25th and April 26th but no reasoning documented for April 21st. Due to this information obtained, the Department finds the allegations 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 cited on the attached LIC 9099-D. An exit interview was conducted, a copy of the report and appeal rights provided to Executive Director. LIC 9099-C Allegation: Staff dropped resident during transfer. Based on interview conducted with R1 revealed R1 needed transferring assistance from the commode to a chair when R1 felt weak. R1 stated R1 was then dropped onto the floor. R1 stated it was a male staff assisting R1 with transfer. File review of R1's LIC 602 Physician Report revealed R1 has dementia. Interview conducted with S1 revealed that S1 was working on call in the night shift and assisted R1 with S2. R1 reported R1 felt weak so S1 and S2 provided R1 with a "guided fall" onto the floor to rest until R1 had the strength to stand. File review of the guided fall internal report revealed that R1 sustained a minor skin tear which first aid was administered. The following allegation is unsubstantiated as R1 is unable to recall the story in multiple settings. Allegation: Staff falsified resident records. File review of the guided fall internal report revealed S1 and S2 assisted in R1's transfer. Interview conducted with S1 revealed R1 is a two person assist with transfer. The night of the incident S1 was assisting R1 with S2. Interview conducted with R1 revealed R1 does not recall who assisted R1 but does recalled S1 to be in the room. Interview conducted with S2 revealed that S2 does not recalled being in the room with S1 to transfer R1. File review revealed no unusual incident report was submitted to Licensing as the incident was a "guided fall" and R1 did not need medical services. The following allegation is unsubstantiated. Based on information obtained, the following allegations are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was provided to Executive Director..