Facility Evaluation Report

On 3-12-24 at 12:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. The purpose of today's case management is to address a facility reported medication error and LPA follow up on a previously reported incident involving resident1 (R1's) absence without leave (AWOL) and Fentanyl found in R1's system. LPA met with Administrator Danica Morrison via phone and explained the purpose of the visit. Administrator gave permission for lead caregiver (S8) to sign in her absence.

Incident #1: LPA reviewed incident report dated 2-15-24 which states on 02/15/2024 at approximately 5:00am during a medication count, it was discovered by night staff that R1's Divalproex was off by 1 count. S8 concluded that she had given 1 dose of his evening Divalproex instead of 2, resulting in a medication error. Staff contacted R1's physician at 8:50am on 2-15-24 to inform him of the error and to get instruction on how to proceed. LPA conducted brief interview with S8 during today's visit and reviewed medication log sheet and orders for R1. It was discovered the medication error occurred on 2-14-24 at 6:25pm.

Incident #2: LPA reviewed incident report dated 12-29-23 and updated 1-2-24 involving R1. This is a follow up to a previous case management addressing this incident and conducted on 1-30-24 as well as additional Department follow up thereafter. LPA conducted interviews with S8, S9, and S10 as well as Administrator. LPA also conducted interview with R1. Additional staff interviews were previously conducted on 3-6-24 via telephone. LPA also reviewed a facility internal investigation completed on 1-9-24 regarding the above incident. Based on interviews and record reviews, it was determine that facility concluded a suspicion of a staff member intending to sell medication to other staff members. It was further determined that this incident of facility's discovery was not reported to licensing agency. A copy of the facility's internal investigation was received by the department on 1-30-24. LPA requested copies of employee internal concern forms from December 2023 to be sent by 3-15-24. Administrator was made aware that additional investigation may be required for the above incident. {Cont. on 809C}