Complaint Investigation Report

RP reported that when the staff were asked about the medication list that was being used, the staff told the RP that the list was faxed to their medication pharmacy however there were no records of the fax being sent. RP reported that the resident is no longer in ICU but is still hospitalized”.

LPA interviewed five (5) staff members (ED, HSD, S1, S2, and S3).

ED stated the staff should have caught the medication by going over the discharge paperwork. R1 has been at a skilled nursing facility since November 2024. The staff went to assess R1 on 02/12/2025 and saw the updated LIC602 and updated medication list. The actual papers/forms were emailed on 02/12/2025. The resident came back to the facility on 02/14/2025 around 10 AM. ED stated that the R1’s primary care physician (PCP) was notified that the facility gave Glipizide medicine which was not on their discharge paperwork.

S1 stated that on 02/14/2025 around 5 PM, they administered Glipizide to R1. The medication was still listed on the QMAR, and there was no discontinuation on it.

S2 stated that they were working on 02/14/2025 when R1 returned to the facility from the skilled nursing facility. S2 stated that R1 brought discharge papers and a medication bag containing medications from the skilled nursing facility. S2 gave the discharge papers to HSD and centrally logged the medications. S2 stated that, to their knowledge, Glipizide was not in the bag. They also stated that they did not know why Glipizide was still listed on the QMAR.

S3 stated that they administered Glipizide to R1 on 02/14/2025 between 7:00 and 7:30 PM. Since Glipizide was listed on the QMAR, they believed it was appropriate to administer it. S3 stated that on 02/17/2025 at 7:00 AM, they went to check on R1 and found R1 sleeping but unconscious. S3 measured R1’s blood sugar at 46 and called 911. S3 did not administer Glipizide or any other medications on the morning of 02/17/2025, as R1 was unconscious. S3 stated that R1’s discharge papers from the skilled nursing facility should have been reviewed to update the QMAR.

HSD stated that they went to the skilled nursing facility to assess R1, and Glipizide was not listed on the paperwork. HSD further stated that the skilled nursing facility did not provide the correct medication list on the discharge papers. The medication list was not current, and they were looking at it as incomplete. HSD stated that Glipizide was not listed in the medication list received when R1 returned to the facility. This medication list was identical to the one received during the assessment visit.