Complaint Investigation Report

Staff did not administer resident's medication as prescribed:

The allegation is that the facility did not administer resident R1's PRN medication to R1.

On 3/12/2024, LPA interviewed Executive Director (ED) Karina Nevarez. ED stated resident R1 is a resident in memory Care Unit, and is under hospice care. ED stated the medication that did not administer to R1 is PRN medication meaning to administer to resident as needed. ED stated the symptoms R1 had were related to the Hospice diagnosis. ED stated the staff called R1's hospice agency for advice. ED stated R1's hospice agency had given the approval for the R1's family member (FM) to carry R1's PRN medication and to administer the medication as need.

LPA interviewed Resident Service Director (RSD). RSD stated resident R1 is under hospice care. RSD stated the protocol for resident who is on hospice care and having symptoms related to the hospice diagnosis is to call hospice nurse for advice. RSD stated on 2/17/2024, R1 had the symptom of chest pain which is the symptoms related to R1's hospice diagnosis. RSD stated the facility staff contacted hospice nurse and Hospice nurse arrived at the facility at approximately 6:00PM on 2/17/2024.

Based on the review of R1's physician report, R1 is on hospice care. Based on the review of R1's Individualized Service Plan, R1's has Special Medical Needs that R1 requires service from hospice staff.

Based on the interview and records reviewed, R1 was under hospice care. R1 had the symptom same as R1's hospice diagnosis. The facility staff are not allowed to administer R1's PRN medication to R1. The facility staff need to call hospice care nurse for advice.

Staff did not seek medical attention in a timely manner:

The allegation is that resident R1's family member (FM) called a facility staff that R1 needed PRN medication when R1 had pain, but it took around 37 minutes to get the PRN medication.