complaint·October 5, 2023

(Continued from LIC9099) All staff members interviewed consistently stated that R1 had a history of refusing medications and the medications were attempted to be given each time, according to the prescription. Staff interview revealed that staff were adhering to the regulation of a resident's personal right to refuse or accept medications, and that they could not force R1 to take them. Outside source interview revealed that the Licensee did not have a history of errors in the timing of medications, or attempts to provide them. Review of facility and outside source records did not provide evidence of a medication error during the timeframe in question. Records review confirmed that the medications in question were refused, not missed. R1 was not able to be interviewed due to refusal. Regarding the allegation, "Licensee did not maintain medication administration record", it was alleged that a staff member (S1) documented R1's medication record incorrectly. Staff and outside source interviews were inconsistent, and revealed that no staff member observed if R1 ingested or did not ingest the medication in question. The Executive Director conducted an internal investigation regarding the matter and the findings were inconclusive. Outside source information regarding the incident was not able to be corroborated due to refusal of the alleged witness identities. Additional outside source interview revealed no knowledge of documentation errors by the Licensee. R1 was not able to be interviewed due to refusal. Records review showed that the Licensee contacted the Department regarding the accusation of a documentation error, and informed of a change in procedure and additional training as a precaution. It is unknown whether R1 ingested the medication, therefore it is not possible to determine if the medication record was in error. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation(s) occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director Richard Mariona, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. (Continued from LIC9099) Outside source interview confirmed that the named pharmacy did not generate or provide the report in question, therefore it did not exist to be given. Regarding the records requested pertaining to a staff member, the Responsible Party did not have the authority to make the request or receive documents for staff personnel's private information. Based on records review and interviews, the allegation that the Licensee did not provide Responsible Party access to records is UNFOUNDED, meaning it was false, could not have happened, and/or is without a reasonable basis. The allegation has therefore been dismissed. An exit interview was conducted with Resident Services Director Richard Mariona, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.