Complaint Investigation Report

Furthermore, there was no indication of an order to stop giving the blood pressure medication, or any indication that R1 refused medication. Progress notes for R1 reviewed revealed three entries regarding medication order discrepancy. An entry on 2-3-22 states pharmacy was called. The following entry was on 2-15-22 which states clinic was called and staff was waiting for a response “within 24 hours.” The last entry was on 2-18-22 which states a staff member notified R1’s responsible person asking for assistance in obtaining a medication list. The progress notes did not specifically state a specific physician was notified to address the medication discrepancy. This information was also confirmed through staff interviews. Based on additional interviews it was determined that Administrator did not ensure a practice necessary to aid in resolving the medication discrepancy for R1 described above.

Based on the interviews conducted and records reviewed, it is determined that the preponderance of evidence standard it met, therefore the above allegations are SUBSTANTIATED. Deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jenna. Appeal rights provided.

This document has been amended to reflect additional citations noted on LIC 9099 dated 4-8-22.