Complaint·November 20, 2023

9099C-1.. On 8/23/23, at approximately 2:32 pm, the resident was transported by ambulance to an area hospital and admitted for an increased altered level of consciousness, weakness, hypotension, respiratory failure and bradycardia (slow heart rate). Resident's urinalysis test returned positive for fentanyl. A second test was not conducted. Fentanyl was not a medication on resident's medication list. Hospital notes were reviewed and note the pulmonologist wrote "Possible false positive urine test due to a cross reaction with other drugs". There was no evidence to indicate the presence of fentanyl in the facility. The Administrator stated that none of the residents were prescribed fentanyl which was consistent with resident record reviews. The Department conducted an on-line search of resident's (R1's) medications and their ingredients, as well as the medication ingredients of all residents, and no medications were determined to contain fentanyl as an ingredient. Resident's medication labels on the medication containers were also reviewed and none were observed to list fentanyl. Both the Administrator and caregiver denied taking fentanyl. The Administrator also indicated that resident (R1) had no access to any medications and did not manage her own medications, confirming the medications were kept locked in a cabinet. The Administrator or caregiver administered all of resident's medications and the resident (R1) did not leave the facility or have any visitors leading up to the incident. The local police department conducted an investigation and was unable to find any evidence of a crime and closed their case as information only. Resident, (R2), reported she received another resident's medication once but immediately recognized the incorrect medication and advised staff. The same resident recalled another time when another resident, whose name was not known, received an incorrect medication and told staff "This isn't mine". Staff corrected the medication error before the resident took the wrong medication. R2 stated that the Administrator will prepare medications for all residents and store them in a kitchen drawer. The Administrator confirmed all medications are stored in a locked cabinet and no where else in the home. The Administrator showed LPA on 11/20/23 that she prepares the medications only for the day (all dosages) and administers the medications with a meal when possible. LPA observed each medicine cup to be labeled with resident's name. As a result of this investigation, the Department finds the allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to the Administrator.