complaint·June 13, 2023

Review of faxes sent from the facility revealed that in April 2023, facility staff submitted R1’s current medication list to their primary physician with a request to review R1’s medications and issue any orders as necessary. The following day, R1’s primary physician faxed R1’s current medication list with no discontinuation orders to the facility. Interviews revealed that R1’s responsible party did not want R1 to continue taking the new medication and requested that the facility stop giving the medication to R1. Interviews revealed that facility staff, including the Resident Services Director and Executive Director, spoke with R1’s responsible party and explained that facility staff were required to follow prescribing orders and a medication can only be discontinued by a physician’s order. They also explained that residents have the right to refuse medications and cannot be forced to take any medications they do not want to. Interviews revealed that facility staff had made several fax and phone call attempts to contact R1’s physician requesting a discontinue order for the new medication. Interviews revealed that some residents’ primary physicians, including R1’s primary physician, did not respond promptly to staff’s request for updated orders, which resulted in follow-up faxes sent by facility staff. Interviews revealed that if facility staff had difficulty contacting a primary physician, staff would notify the Resident Services Director who would reach out to the primary physician and would ask the resident’s responsible party to request the discontinue order from the primary physician as well. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Jackie Banks, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.