Complaint Investigation Report

During the investigative process, it was indicated and verified that the resident (Resident 1) could not determine, per the physician’s order that she could indicate when she needed a Pro Re Nata (PRN). The physician ordered that the resident take Lorazepam and Phenobarbital on an “as needed basis” for anxiety. Staff did utilize the PRN order and stated that they did contact the on-call hospice nurse to get permission to give additional dosage; however, documentation could not be provided to support that the staff did call the hospice nurse when giving the PRN. It could not be proven one way or the other if the staff were over medicating the resident in care.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above finding is Unsubstantiated .

Note: The regulations clearly state to record the date and time of each contact with the physician. In this case the staff were to contact the hospice nurse prior to giving the resident the PRN for Lorazepam and Phenobarbital, provide the date and time of each contact with the physician (hospice) and the physician’s (hospice) directions, were to be documented and maintained in the resident’s facility record. A separate citation will be given on an LIC 809 document indicating that the staff did not document when the hospice nurse was contacted to provide the resident with the PRN.

Staff did not report incident(s) involving resident as necessary .

During the interview process, the assistant administrator, two hospice nurses and three staff persons were interviewed. The residents were not interviewed due to their dementia status. In addition, the following documents were obtained and reviewed: Physician’s Report, Medication Administration Records (MARs), Daily Care Logs, Admission Agreement, staff work schedules, and staff telephone numbers.