Complaint Investigation Report

orders, facility’s medication list, and the Centrally Stored Medication Log (CSML) for resident (R1). Two [2] discrepancies were found. A discrepancy was found in regard to the medication Gabapentin. The doctor’s orders show R1 was to receive two [2] tabs of 100mg gabapentin three times per day. However, both on the facility’s medication list and the CSML, the dose of gabapentin required was listed as only one [1] 100mg tablet three [3] times per day. During investigation, LPA interviewed staff that reported the medication dose had been lowered from two tabs to one tab on 10/22/24. However, the hospital discharge papers were dated 10/11/24 and they included the prescription documentation for the gabapentin. Per LPA review, the dose R1 was to receive was listed as two [2} tabs three [3] times per day, and therefore no change had been made to the accounts of the total number of gabapentin tablets R1 was to receive.

Additionally, on 10/11/24, R1 was prescribed 20 mg of prednisone, three [3] tablets to be taken every morning for a total of 5 days. During investigation, staff advised LPA that since the medication was only prescribed for 5 days, that it wasn’t added to the CSML but was added to the Medication Administration Record (MAR) instead. However, LPA observed the prednisone prescription added to the CSML. LPA also observed the MAR to indicate that the prednisone was administered to R1 on 11/11/24-11/15/24. However, the resident did not return from the hospital until after 5:00pm on 11/11/24 and per the physician’s order’s the prednisone was to begin being administered by the facility on the morning of 11/12/24. During investigation, LPA received evidence that R1’s prednisone prescription filled on 11/11/24 had 8 out of 15 pills remaining. Based on LPA observation and evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

Complaint alleges staff did not ensure carpet was clean resulting in resident's feet getting dirty. During investigation, LPA received police report. Witness (I2) reported that they observed the carpet in R1’s room to be dirty, R1’s bathroom floor to be sticky, and noticed R1’s feet to be dirty. I2 indicated that R1’s feet were dirty due to walking on the sticky bathroom floor then subsequently walking on the dirty carpet. Additionally, witness (I3) reports observing R1’s carpet to be heavily soiled and R1’s feet to be blackened with dirt. Based on evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.