complaint·September 26, 2024

On 08/27/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding Resident #1 (R1) alleging that on 08/19/2024, the administrator of the facility accidentally placed the 8:00am medication for R1 in the 12:00pm dispensing cup, and the 12:00pm medication for R1 in the 8:00am dispensing cup. Facility staff noticed the mistake during the passing of medications at 11:45am and called the primary care physician of R1 but received no answer. Staff additionally called the responsible party for R1. The vitals of R1 were checked and they were placed on 15-minute charting. The UIR stated R1 was orientated, no altered state, no signs of distress, no complaints of dizziness, discomfort, or pain. On 08/28/2024, the Department received a self-reported UIR regarding R1 alleging that on 08/20/2024, facility staff poured/administered medication for R1 out of a bubble pack and a portion of the medication had broken apart while being popped out of the pack. On 09/10/2024, LPA conducted an initial complaint investigation visit to the facility. LPA requested and received relevant documentation from the facility pertinent to the allegations and interviewed Staff about the incidents involving R1. LPA received Addendums to both the 08/19/2024 and 08/20/2024 UIRs regarding medication errors for R1. The addendums provided additional details of the errors by the administrator on 08/19/2024, and the facility MedTech on 08/20/2024. Staff interviewed by LPA stated that on 08/20/2024, they were distracted by another resident at the door to the medication room when they popped the pill out of the bubble pack. When staff popped the individual pill into the cup meant for dispensing medication to R1, they did not realize that all of the pill had not been popped. Staff stated there had been a call to the facility by responsible party of R1 to state not all of the pill had been dispensed. Staff then checked the medication room and found the missing piece of the pill that had broken off when popped out of the bubble pack. Staff stated R1 was getting picked up early that day (8/20/2024) so they communicated with other staff and gave R1's medications to R1' responsible party for release while R1 was out of the facility. The medications for release were placed in a sealed envelope, the envelope was labeled by Staff and R1's responsible party. On 09/24/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding resident #1 (R1) alleging that they had a medication error on 09/16/2024, caused by facility staff. The UIR noted that on 09/16/2024, at approximately 6:30am, facility Staff poured the 8am, 12pm, and 2pm medication for R1. Facility staff stated that the 12pm medication for R1 was pre-cut from 09/15/2024, as R1 is prescribed 5mg per dose and the medication received from the pharmacy arrives to the facility as a 10mg pill. Staff stated that the 12pm medication may not have been precisely divided in half as there appeared to be bits of broken/crumbled pill. Continued on 9099-C To prevent this from occurring again, the facility requested and received 5mg size medication pills from the pharmacy that no longer need to be cut at the facility for R1. On 09/24/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding resident #1 (R1) alleging that they had a medication error on 09/21/2024, caused by facility staff. The UIR noted that on 09/21/2024, facility staff did not give R1 their 12pm medication as staff did not see the medication in the Medication Administration Record (MAR). Staff did see the 12pm medication for R1 in a dispensing cup in the facility medication room. However, staff was confused and thought it might be prior medication from a previous dispensing to R1. Staff did not realize this mistake until the next day on 09/22/2024, and the blood pressure of R1 was not checked at 12pm for R1. Staff was counseled on safe medication preparation and medication training was conducted. The facility/Licensee policies and procedures on resident medications were reviewed. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. On the allegation: Facility staff did not appropriately communicate a change of condition. It is alleged the blood pressure of R1 at 11:30am on 08/19/2024 constituted an overdose as blood pressure medication was the missed medication for R1 in the 08/19/2024 missed medication incident. It is alleged that the facility did not appropriately report a change in condition of R1 to their Primary Care Physician at the time of the missed medication incident on 08/19/2024. The allegation states that in the UIR provided to the Department, the facility stated that they had spoken to the Reporting Party (RP) prior to providing R1 an electrolyte drink. However, allegedly RP was not spoken with by the facility prior to providing R1 with the electrolyte drink. Based on staff interviews and record review conducted by LPA on 09/10/2024, when the medication error regarding R1 on 08/19/2024 was discovered by the facility, staff attempted to communicate a change of condition in R1 to their Primary Care Physician (PCP). However, the PCP for R1 was at lunch and unable to speak to facility at the time of the medication error. The facility called the PCP by telephone but did not leave a voice mail message at the Doctor's office so there were no calls documented and the doctor's office did not know anything was wrong. On 09/10/2024, LPA received self-reported Addendum UIRs for the 08/19/2024 and 08/20/2024 medication incidents involving R1. The 08/19/2024 addendum included information that at 1:26pm, facility staff gave R1 an electrolyte drink prior to speaking with the responsible party of R1. However, at 1:36pm, the administrator spoke with the responsible party of R1 who advised the administrator to give R1 an electrolyte drink. Continued on 9099-C At the time of the phone call at 1:36pm, the facility administrator was not aware that facility staff had already given R1 an electrolyte drink at 1:26pm. Regarding the 08/19/2024 incident involving the blood pressure medication of R1, the facility attempted to contact the responsible party of R1 by telephone within half an hour of the facility realizing the medication mistake but received no answer. The facility was able to speak with the responsible party of R1 within an hour and a half of the realization of the medication mistake and communicated what had happened. A family member of R1 physically visited the facility two and a half hours after the realization of the medication incident and stayed at the facility for two hours. R1 was reported to be oriented, no altered state, no signs of distress, no complaints of dizziness, discomfort, or pain. The facility documented all significant occurrences that may result in changes in the resident’s physical, mental and/or functional capabilities and immediately attempted to report these changes to the resident’s physician and authorized representative. Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated. Exit interview conducted. Copy of this report provided to the facility.