complaint·June 15, 2023

LPA was provided pictures of the Excedrin Migraine bottle provided to the facility. There was one Kirkland “Migraine Headache Relief” Bottle (250mg Acetaminophen, 250mg Aspirin, 65mg Caffeine), 400 count with a lid that has “NOC” written and “noon” “evening” and “bedtime” stickers. There is another sticker that says “Directions: 2 tab po 4 times a day” on that bottle. There was also an Excedrin Migraine bottle with a “morning” sticker on the lid. The reporting party stated no Acetaminophen bottle was returned to R1 when they moved out of the facility. Reporting party stated they feel R1 was given the Kirkland Migraine Headache Relief instead of Acetaminophen. The Kirkland Migraine Headache Relief has Acetaminophen in it, and it was possibly given 4 times a day as the Acetaminophen, in addition to the 2 tabs of Excedrin Migraine. LPA visited the facility on 3/2/23 and observed there to be leftover medication for Resident 1 that was not picked up, including a Kirkland Acetaminophen Extra Strength 500 count bottle. LPA interviewed MedTech’s who said it was possible that the Kirkland Migraine Headache Relief was given instead of the Acetaminophen, because the bottles look almost identical and both have acetaminophen as the first ingregient. When LPA interviewed the MedTechs, LPA showed them pictures of the two bottles (Acetaminophen and Kirkland Migraine Headache Relief) and asked which medication they would give for Acetaminophen. Only one MedTech indicated they would give the Kirkland Migraine Headache Relief, then later stated they were only 50% sure, while the rest of the MedTechs stated they were not sure. Wellness Director stated that while it is very possible the bottles were mixed up because they both have Acetaminophen as the first ingredient, there is a 7 step process that Medtechs go through to ensure the right medication is being given. Wellness Director stated for example, the process is for the Medtech to pull out all bottles that had “morning” on them that would have included the Excedrin Migraine, Kirkland Migraine Headache Relief, and Kirkland Acetaminophen and go through each order for the morning to make sure the correct medication is dispensed. However, they could see the possibility of them dispensing the Migraine Headache Relief as Acetaminophen because they look so similar and appear to match. LPA interviewed the family who stated they can’t remember if they gave the facility a brand new bottle of any medications or if some were opened. LPA reviewed the Centrally Stored Medication and Destruction Record, which indicated the quantity were full bottles, but the Medtech’s interviewed stated they didn’t know they had to count the medications received if the bottles were open. This will be addressed in a Case Management visit. Continued on 9099-C Based on the information obtained, there is not enough evidence to prove an incorrect medication was given, therefore the allegation is deemed Unsubstantiated at this time. LPA recommends the facility provide additional medication training to MedTechs to ensure they fully read the bottle of medication, instead of relying on how the bottle looks or on stickers. Exit interview conducted, copy of the report was printed and emailed.