complaint·December 14, 2023

Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced on 12/14/23 at 11:30 AM to deliver complaint findings, LPA Renee Campbell met with Associate Executive Director and explained the purpose of the visit. Allegation #1: Staff mismanage resident’s medication. When interviewed, H1 stated that hospice had to ask the husband to step out so that staff could directly ask R1 if she wanted pain medication. Per H2, R1 asked for pain medication more “towards the end of her decline”. LPA Campbell observed that the Medication Administration Record (MAR) was completed correctly in regard to the doctor’s orders. S1 also explained how staff ensured R1 gave consent for pain management. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude that the staff mismanaged resident’s medication. Both the doctor’s directives and the clients requests were followed as required. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.