complaint·March 28, 2023

Continued from LIC9099... A finding that the complaint allegations “Staff mismanaged resident medication” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation stating Staff did not adequately store medications. It was alleged that medication was observed by Reporting Party sitting on R1’s couch at the facility. LPA conducted confidential interviews with witnesses including hospice agency nurses that were conducting consistent visits to the facility who expressed that they did not observed any issues with medications storing, there were no concerns or have observed R1 being uncomfortable nor complained about pain. Also, it was disclosed that R1 did not believe on medication treatments and was consistently refusing medications. Based on records review of incident report logs, R1 was consistently refusing medications and facility notified pertinent parties about it. LPA has determined and confirmed that although R1’s baseline belief system was against medications, there was no indication that any dosage was missed or not stored properly by facility staff. A finding that the complaint allegations “Staff did not adequately store medications” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff not adequately trained to meet the needs of resident in care. Per Reporting Party, they were told that the facility staff were not adequately trained to care for R1. Also, the staff did not know which resident’s records they could provide because the hospice agency oversaw medications. Based on observations of facility training records, LPA learned that the facility does onboard training of staff members. Based on records review, LPA confirmed staff medication training records are current. On 2/10/23 LPA conducted 10-day visit and observed sufficient staff members at the facility. A finding that the complaint allegations “Staff not adequately trained to meet the needs of resident in care” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continues on LIC9099C... Continued from LIC9099C... It was alleged that the facility did not provide resident’s records to responsible party. Per Reporting party alleged that facility staff was contacted by R1’s power of attorney (POA) to request R1’s medication records and staff told them that they could not provide records because they did not know which documents they could provide because the hospice agency was in charge of R1’s medication records. Based on records review, on 2/10/23 facility provided electronic communication records to LPA dated 2/9/23 at 4:47pm from R1’s responsible party requesting R1’s invoices and health care directive. On 2/9/23 at 7:39pm, facility responded to their request email, providing them with two pdf files including R1’s hospice file and pre-hospice medications, one is R1’s medication changes and the body of the email indicating them that the facility have sent to their accountants to provide them with monthly invoices. On 2/10/23 at 12:42pm the facility provided R1’s responsible party via email R1’s invoices since R1 was admitted to the facility. Based on confidential interviews, LPA was informed by facility and responsible party that records requested were released to R1’s responsible party as of 2/10/2023. Based on information received by the Licensee and reporting party, it was confirmed that records were provided to R1’s responsible party. A finding that the complaint allegation “Staff did not provide records to resident's authorized person” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today’s visit.