Complaint·May 19, 2023

LPA interviewed S3, current acting administrator, on 05/10/2023. S3 stated that they were not called and had no communications of R1’s swollen leg, the contact with F1 or the Primary Care Physician visit on 04/17/2023. S3 stated that on 05/10/2023 at approximately 11:00am was the first time that they heard of R1’s change of condition and the doctor’s visit to the facility to see R1. Based on Interviews and documentation, the allegation of, “Facility staff did not notify resident’s physician of change in resident’s condition.” Is substantiated at this time. As to the allegations, “Facility staff mismanaged resident’s prescription,” “Facility staff did not ensure that resident received medication as prescribed” and “Facility staff falsified resident's medication record.” It was alleged that the facility did not ensure R1 received a medication as prescribed, that the facility did not assist R1 in obtaining the prescribed medication from the pharmacy, and that the facility incorrectly documented R1’s medications. It was discovered through documentation and interviews that on 12/07/2023 a prescription of Medication (Med1) was filled through CVS Pharmacy on 12/07/2023 for R1. Facility Medication record provided by R1’s responsible party at time of R1’s admission to the facility on 12/16/2022, indicated that R1 had a total of 4 medications prescribed. LPA collected and reviewed facilities monthly Medication Administration Records (MAR) of R1 for the months of December 2022, and January, February, March, April, and May of 2023, which 4 of 4 medications were noted on each and all the monthly MARs, including Med1. LPA interviewed S1 and S2 on 05/10/2023, LPA asked both S1 and S2 if they recalled assisting R1 with Med1 prior to 04/10/2023 (when R1 returned from the hospital with new prescription of Med1). LPA showed physical bottle of Med1 to S1 and S2 as well as pointed out on the monthly MAR of which Medication LPA was referring to. When asked about assisting R1 with Med1, both S1 and S2 indicated that they had not assisted R1 with Med1 until 04/20/2023. Both S1 and S2 did not recall ever having Med1 at the facility until 04/20/2023 when R1 returned from the hospital. LPA asked both S1 and S2 why they initial on a daily basis for the last 6 months that the Med1 had be given to R1 on each of the monthly MARs when there was no Med1 to give, and they both state, “I don’t know”. LPA requested LIC622 Centrally Stored Medication and Destruction Record from the facility, however the facility did not have a Centrally Stored Medication Record for R1 at the time of investigation visit and again on 05/12/2023 when LPA made a phone call request for the Centrally Stored Medication inventory for R1. CONTINUED on LIC9099-C. Based on interviews, and documentation Med1 which was prescribed on 12/07/2022 was not provided to the facility when R1 was admitted on 12/16/2022 and not obtained until R1 returned from the hospital on 04/20/2023. The facility documented that Med1 was taken by R1 from 12/16/2022 until R1 was hospitalized on 04/17/2023, which was not accurate based admission of S1 and S2 and confirmed by R1’s primary physician and supported by results of testing from R1’s hospitalization on 04/17/2023 through 04/20/2023, therefore the allegations, “Facility staff mismanaged resident’s prescription,” “Facility staff did not ensure that resident received medication as prescribed” and “Facility staff falsified resident's medication record” are substantiated at this time. Exit interview, report read, citations issued, appeal rights and report provided.