Complaint·August 14, 2023

(Report Continued from LIC 9099...) It was alleged that staff do not ensure that residents are receiving their medications as prescribed. It was reported that residents were given different medication from what is prescribed. Review of records revealed that Resident #1 (R1) has two (2) PRNs for pain medication which include Acetaminophen 500mg oral tablet and Acetaminophen-Codeine 300mg-30mg oral tablet. The staff utilize the medication administration record (MAR) to also keep track of the PRN medications being administered to residents. Interview conducted with resident revealed they are not sure what medication is given to them; however, the medication that is given to manage the pain helps them to go to sleep at night. Furthermore, although R1 may not know what medication they are taking, the staff is aware of which medication to administer to R1 by following the prescribing doctor’s order on file. Based on record review and interviews conducted, the Department does not have sufficient evidence to support the allegation of “staff do not ensure that residents are receiving their medications as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued. (Report Continued from LIC 9099A...) It was alleged that staff are not properly managing residents' medications. It was reported that several residents’ prescribed narcotics had gone missing. Information obtained during the course of the investigation revealed the facility conducted an audit on residents’ narcotic inventory after several residents’ medication had gone missing. The audit revealed there were at least two (2) residents that had both Tylenol with codeine and Oxycodone missing from inventory. Interviews conducted with staff revealed the narcotics were searched throughout the medication room drawers, cabinets, and resident’s prescription medication, but were still not found. Staff stated R1’s doctor was notified to have new order sent to replenish missing narcotics. Additionally, Resident #2’s (R2’s) doctor was also notified; however, staff requested that R2’s prescription for narcotics be discontinued as R2 has not been at the facility for about one (1) month. Furthermore, R1 and R2’s missing controlled medication has not been found as of today. Based on all the information gathered during the course of the investigation, the above allegation, “staff are not properly managing residents' medications” is deemed Substantiated at this time. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D). Failure to correct citations can result in civil penalties. Exit interview conducted. Citation issued. A copy of the Appeal Rights and Report was issued.