Complaint Investigation Report

On the allegations " Medication is being administered without physician’s order and Resident sustained a fall due to lack of care"; it is the concern of the reporting party (RP) that Resident 1 (R1) was being administered Carbidopa-Levodopa medication for at least two (2) weeks, even though it had been discontinued at R1’s skilled nursing facility prior to re-admission to Arianna Kay Home. It was further reported that this medication made R1 sick, inability to walk independently, leading to a fall at the home, and subsequently being admitted to a hospital on 01/21/2024. Furthermore, the RP reported that the information was provided to them, R1 was admitted to St. Johns Medical Center for a UTI, AKI, confused and restlessness, and they do not know if the medication/fall was a contributor for R1 being at the hospital. Date of the fall was not provided. To investigate the allegation the LPA conducted a file review and interviews.

File review revealed that R1 was at Glenwood Care Center, a skilled nursing facility (SNF), from 10/6/2023 to 12/5/2023. A review of R1’s discharged paperwork from Glenwood Care Center dated 12/05/2023, indicated that R1 had active orders for Carbidopa-Levodopa at the time of discharge.

A review of R1’s incident report (IR) dated 01/11/2024, revealed that R1 had a fall on 01/11/2024. The IR indicated that around 5:00 a.m. staff noticed R1 rolling from their bed and R1’s right side of their head hit the nightstand, sustained a bump on their right forehead and small scratch, and staff immediately did cold compress on R1’s head. A review of R1’s Medical/Dental appointment record dated 1/11/2024, indicated that R1 had a telehealth appointment with their primary care physician (PCP) the same day, and the Administrator was given treatment instructions. A review of R1’s incident report (IR) dated 1/21/2024, revealed that per R1’s PCP order, staff needs to monitor R1’s Oxygen level and temperature due to UTI and weakness and on 1/21/2024, around 7:30 a.m., staff checked on R1’s Oxygen level and it was at 80, the staff called 911, and R1 was taken to the hospital.

Administrators revealed that when R1 was discharged from Glenwood SNF all their medications were sent to Neighborhood Pharmacy, and the pharmacy sent it to Arianna Kay home on 12/05/24. The Administrator took R1 to their PCP on 12/07/2023, but R1 was also seen prior to being discharged from the SNF on 12/01/2023. Their PCP administered a physical exam to make sure R1 was well enough to return home. The Administrator took R1’s December MAR for them to review. Interview conducted with R1’s PCP on 02/07/2024, revealed that they had prescribed Carbidopa, however they could not remember the date. They revealed that it was a low dose, and R1 had a prescription in 2021, and that something must have triggered for it to be prescribed again at Glenwood SNF, and refill requests were sent and were approved. Report will continue on LIC9099-C, 3rd page.