Complaint Investigation Report

S1 reported that R1's responsible party arrived at the facility shortly after the call and took R1 to urgent care. S1 reported that normally they would wait for the physician or nurse practitioner to respond with a prescription or over the counter (OTC) medication to administer to the resident but R1's responsible party decided to take R1 to urgent care and when they returned they had prescriptions and medications for R1 to treat R1. The Wellness Director reported they were notified about the issue and spoke to R1's responsible party who informed them all the facility had to do was administer the medication. The Wellness Director reported that the prescriptions and medication prescribed for R1 were all verified so they administered the medication. The facility followed their procedure for the incident and contacted R1's PCP and were waiting for a response from R1's PCP on how to proceed. S1 and the Wellness Director reported it was not an emergency that required hospitalization or emergency services so an ambulance and/or 911 were not called. R1's responsible party verified that they took R1 to urgent care right after receiving the call from the facility. A review of R1's progress notes shows R1 saw their nurse practitioner on April 1, 2025, at the facility and R1 was observed to have swollen feet and a swollen toe. Medications and blood tests were ordered for R1 after the visit. On April 3, 2025 the blood draw was completed and on April 4, 2025 the new medications arrived and administered to R1. There was no mention of any swelling for R1 mentioned prior to April 1, 2025. On April 22, 2025 R1 was observed to have constipation. S1 and the Wellness Director informed R1's PCP and responsible party. S1 and the Wellness Director reported that the responsible party requested they give R1 prune juice. S1 reported they complied with the request. S1 reported that the issue wasn't an emergency and R1 did not report they were in pain so they waited for R1's PCP to respond to the report. The Wellness Director reported that R1's responsible party came to the facility to visit R1. The Wellness Director reported that the responsible party told them that R1 had a bowel movement and they were fine so they were taking R1 back home. The Wellness Director reported that R1 never returned to the facility and they never heard from R1 or they responsible party again. In each instance R1 received the proper medical care required and the facility responded in the proper manner and sought non-emergency medical care. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, staff ordered medications for resident in care without proper authorization, revealed the following. It was reported that the Wellness Director ordered medications for R1 and had the orders filled without proper authorization on January 6, 2025.