complaint·April 25, 2024

Staff do not ensure that residents' medications are disposed of from the facility . During the interview process, documents were obtained to include the medication room audit, MAR/Narcotics weekly audit for five weeks and the centrally stored medications destruction document. During the investigation process, the administrator, the resident care coordinator and three staff persons related to the medication room were interviewed. In addition, LPA Boyles toured the medications room for a medication review with the administrator and the resident care coordinator. LPA Boyles reported that she observed the medications that were waiting to be destroyed. The administrator reported that sometimes there is a delay in destroying medication because as their policy states, two nurses must be present. The administrator reported that sometimes due to competing demands, medication destruction is not prioritized and is rescheduled. However, medication is destroyed within the parameters outlined within the program plan. Staff do not store residents' medications locked and inaccessible to residents . During the investigation process, the administrator, the resident care coordinator and three staff persons related to the medication room were interviewed. In addition, LPA Boyles toured the medications room for a medication review with the administrator and the resident care coordinator. It was reported by LPA Boyles that all medications were locked and inaccessible to residents. During the interview process none of the persons interviewed indicated that they have seen medications unlocked. Staff do not conduct audits of residents’ narcotic medications . During the investigation process all staff indicated that the residents’ narcotic medications are audited daily with a two-person review. In addition, documents were received of the medication room audit and MAR/Narcotics weekly audit for five weeks. During the interviews and documents reviewed, there was no indication that staff do not conduct audits of residents narcotic medications. Although the above allegations mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and all of the above findings are Unsubstantiated .