Complaint Investigation Report

Allegation: Facility staff mismanages resident's medication. It is alleged that the facility failed to administer medications according to doctor’s orders.

On 09/13/2023 R1 stated her blood pressure was high and asked Med-Tech for additional ½ dose of Hydralazine as her doctor had ordered back on 12/29/2022. Facility staff refused to give it to R1 telling her that they required a doctor’s order and could not locate any current doctor’s order that allowed facility to provide an extra ½ a tablet. On new doctor’s orders dated 05/16/2023 provided to facility it only included for Hydarlazine to be provided 3 x per day without the additional ½ tablet PRN and facility was acting based on that order. However, on the actual medication for Hydarlazine bottle filled on 7/23/2023, The orders are for 3 tablets per day and additional ½ tablet if SPB is over 150. The doctor’s order’s and label on the bottle must be identical and it was not.

Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See 9099D for details.

Exit interview conducted with Crystene Char, Administrator, a copy of this report is being provided and Appeal Rights were given.