Complaint·May 10, 2024

Continued from LIC9099 Review of R1’s Electronic Medication Administration Record (EMAR) for December 2023, showed that R1 had two routine morphine orders to be given twice a day. Review of R1’s EMAR indicated that the facility administered the routine morphine orders on 12/15/223, 12/16/23, 12/17/23, and 12/18/23. These two orders were discontinued on 12/15/2023 and 12/18/2023. R1 also had a PRN morphine order to be administered as needed for pain or trouble breathing and a PRN Lorazepam order to be administered as needed for anxiety. Review of R1’s EMAR showed that facility staff administered PRN Morphine and PRN Lorazepam two times to R1 on 12/22/2023. Facility Progress Notes stated that on 12/19/2023, R1’s private caregiver said R1 needed Ativan. Per notes, the facility nurse observed R1 to be calm and peaceful. When the facility nurse asked R1 if they wanted Ativan, R1 stated no. Facility Progress Notes also stated that on 12/21/2023, the facility nurse received a call from R1’s private caregiver asking for Ativan. Facility Nurse and Certified Nursing Assistant (CNA) went to R1 to assess. Facility nurse and CNA observed R1 to be in a calm and pleasant mood. When R1 was asked how they were feeling, they stated they were fine. When R1 was asked if they felt anxious or if they wanted Ativan, R1 stated no. Review of R1’s Physician’s Report, dated 12/25/2022, stated that R1 can communicate their needs. Based on document review and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.