Complaint Investigation Report

LPA Colvin observed that despite staff's statement that PRN medication is given as often as stated on the prescription, there were not administrations of the PRN of Quetiapine Fumarate or notes of refusals for the month of September until the 20th, no administration Cetirizine in September 2022 or October 2022, and sporadic administration of PRNs Acetaminophen and Hydrozyzine. Additionally, LPA Colvin observed notes for Buspirone (9/1/22 - 9/21/22, 9/26/22 - 10/4/22) and multiple other medications for 10/1/22 through 10/3/22, which stated "Physically unable to take". LPA Colvin inquired with staff what this note means and staff stated that they did not have the medication for the resident and were waiting for a refill. LPA Colvin reviewed the Centrally Stored Medication Log which showed the medication refilled on 9/26/22, but staff stated that the date listed is not the date received, but the date the order for refill was placed with the pharmacy. LPA Colvin inquired about the missing doses for September, and staff stated that there were issues with getting the medication refilled as R1 had not seen their Primary Care Physician (PCP), and the prior prescriptions were from the hospital. It should be noted that Busporone is prescribed to be taken by the resident twice daily for agitation, and is not a PRN.

Since the facility has not administered all of R1's medications according to physician's orders as noted above, the allegation " Staff did not provide medications to a resident while in care" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Executive Director Shannon Wilkerson during the exit interview.