Complaint Investigation Report

Additionally, on 03/22/24 Administrator Yanett Aguilar emailed LPA the following documents: MARs for December and January for C1, Physicians order for extra treatment along with fax confirmation sheet, and a copy of a message thread from C1 and Physician.

The Investigation revealed the following: Regarding the allegation: Staff mismanaged resident medication. It is alleged that staff declined to administer PRN medication to client when requested, because they did not have written orders. On 02/02/24 at 10:00 AM, C1 was given their medication. Then at 12:00 PM before leaving for their doctor’s appointment, C1 requested additional medication, staff then advised C1 they were not able to give C1 their medication because it had not been 4 hours since the last dose was given. On 2/2/2024 while on their way to their doctor’s appointment, the client had an asthma attack, staff then gave the client their inhaler, but that did not resolve the asthma attack. The client then urinated on their pants but were able to calm themselves down. Staff tried taking the client to the emergency room, but the client declined and requested to be taken back to the facility. Before arriving at the facility, the client had another asthma attack. Staff then gave C1 their medication at 2:00 PM when they arrived back to the facility and that resolved the second asthma attack.

On 03/22/24 LPA assessed the Medication Administration Records (MAR) (dated: 12/01/23-12/31/23, (01/01/24-01/31/24, 02/01/24-02/29/24), Physician Telephone Communication Form dated 02/05/24 with written orders stating that client (C1) can have PRN medication every 4 hours as needed and that it is okay to administer an extra treatment(s) before going out on trips or errands. Evidence revealed that up until 02/05/24 staff were following orders and only administering medication every 4 hours as needed per the physician’s written orders. A new order was received on 02/05/24 allowing for additional treatments.

An interview conducted with 1 (C1) client revealed that staff have refused their medication in the past. LPA was unable to interview 2 out of 3 clients. Interviews conducted with 7 out of 7 staff (S1-S7) revealed that proper medication protocols are followed, and medication is distributed as prescribed on physician’s written orders. Based on interviews conducted 5 out of 7 staff (S2) and (S4-S7) stated that C1’s PRN order stated that the client could have the medication every 4-6 hours as needed, but it recently changed as of 02/05/24 and can now be administered every 4 hours as needed, and that It’s ok to administer extra treatments prior to going out on a trip or errands.