Complaint Investigation Report

On the allegation: Staff mismanaged resident’s medication. According to R1’s physician report, signed and dated 03/30/2023, the primary diagnosis was listed as dementia. R1 was not identified with motor impairment or paralysis. R1 was identified as being confused/disoriented, with wandering behavior, sundowning behavior, but was listed as being able to follow instructions and communicate needs. R1 was listed as ambulatory and could independently transfer to and from bed. The report documented R1 was able to dress, groom, feed self, and care for own toileting needs. The resident appraisal information, dated 03/30/2023, indicated R1 had moderate dementia, used a walker, was listed as non-ambulatory, but did not need help transferring in and out of bed or chair. Facility records indicated R1 was admitted to the facility on 04/01/2023.

R1’s Centrally Stored Medication Record (CSMR) was reviewed. The record lists three (3) dates filled (04/07/2023, 04/22/2023, and 05/06/2023) for the medication Quetiapine 50 mg. The instructions on the record are listed as “take 1-2 tabs at bedtime as needed”. “As needed” indicates that this medication was prescribed as a PRN (Pro re nata). The facility did not have a specific order for an exact dosage for R1’s PRN (as needed) Quetiapine medication and should have clarified the order with R1’s physician. A review of the facility’s “As Needed Medication Record” dated 04/07/2023, revealed that R1 was being given a dose of Quetiapine 50 mg routinely every night at bedtime, and not as prescribed on an “as needed” basis. Some of the entries are listed with doses of 50 mg, other dates and doses indicate 100 mg was given. The record listed the Quetiapine as being given routinely at every bedtime, with an “effectiveness” consistently noted as “calm” or “sleeping”. These records are dated from 04/07/2023 through 07/27/2023. This indicates that during this time period, the facility staff gave R1 a PRN Quetiapine as a routine daily medication and not as ordered as a PRN, which should have only been given on an as needed basis. Later, R1’s physician changed the Quetiapine dosage to 75 mg, citing that 100mg (2 tabs) was too much for the resident and causing them to be to sleepy.

Based on the information obtained, there was sufficient evidence to show R1’s medication was not given as prescribed. Therefore, the allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.