LPA reviewed the MARs from June 1, 2025 through August 1, 2025. Review of the June 2025 MAR showed that Famotidine 20 mg, ordered once daily, was not given from June 12, 2025 through June 30, 2025 due to the medication being “not available at the facility.” Gabapentin 300 mg, ordered daily, was not given on June 30, 2025, as there was no staff initial recorded. Morphine 15 mg, ordered every 4 hours, was not given on June 29, 2025 at 12:00 a.m., as there was no staff initial recorded. Potassium Chloride ER 10 mq, ordered once daily, was not given on June 29 and June 30, 2025, as there were no staff initials recorded.

Review of the June 2025 MAR also showed that Miralax Powder (Propylene Glycol), ordered 17 grams once daily and to be held for loose stool, was documented as given daily from June 12, 2025 through June 30, 2025, as evidenced by staff initials. This documentation contradicts Patrick’s statement to family that R1 stopped taking this medication after doctor visit. Review of the July 2025 MAR showed that Miralax Powder continued to be given daily from July 1, 2025 through July 31, 2025, as evidenced by staff initials.

LPA also reviewed a medication order dated June 5, 2025, for Morphine Sulfate 15 mg, ordered to be given one tablet every 4 hours. However, the MAR indicated that Morphine 15 mg was being administered every 6 hours, as shown by the recorded staff initials. This indicates the medication was not administered according to the physician’s order.

Based on interviews and record review, the facility did not ensure medications were consistently available and administered as prescribed. In addition, there were discrepancies between staff statements and MAR documentation. Therefore, the allegation that staff did not provide medication assistance as prescribed is substantiated.

A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

LPA reviewed text messages dated June 19, 2025 at 12:44 p.m. between staff members Patrick and Renae and R1’s family members. In the messages, family stated that R1 fell backward in their wheelchair in the morning. Family reported that the wheelchair did not have an anti-tip feature and that R1 complained of back and neck pain. Family also stated that R1 had diarrhea and soiled self that morning while family was visiting. Family expressed concerns about medication and stated that R1 told that R1 was not receiving the 6:00 a.m. morphine pill on time. Family confirmed that R1 told the same concern about R1's medication being late.

In response, Patrick stated by text that the facility does not provide wheelchairs and that R1 was using a loaner wheelchair until he could obtain one through his primary physician or purchase one on his own. Patrick stated that R1 no longer received Propylene Glycol after doctor visit. Patrick also stated that he spoke with staff and R1, and both confirmed that R1 was receiving his 6:00 a.m. medication on schedule. Patrick indicated that he set alarms to help ensure medications were given on time.

Based on interviews and records reviewed, there is conflicting information regarding whether R1 fell or almost fell. Staff reported that R1 did not fall and that he was assessed right away with no injuries noted and no need for medical care. Although family reported that R1 complained of back and neck pain, there is no documentation showing visible injury or that R1 requested medical attention at that time. The text messages show that staff communicated with the family on the same day regarding the incident.

Based on the information obtained, there is not enough evidence to prove that staff failed to seek timely medical attention for R1. Therefore, the allegation is unsubstantiated.

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During interview, staff stated that when R1 was admitted to the facility, R1 arrived with a large wheelchair that did not fit through the bathroom doors. Staff reported that the family asked if the bathroom doors could be removed to allow the wheelchair to fit. Staff stated they were unable to remove the doors because the bathroom is shared with other residents and removing the doors would violate the privacy rights of others in care. Staff stated that instead, they provided R1 with a smaller wheelchair as a loan until the family could provide an appropriate wheelchair. Staff reported that text messages between staff and the family confirmed this agreement.

LPA reviewed text messages dated June 19, 2025 at 12:44 p.m. between staff members Patrick and Renae and R1’s family members. In the messages, on family stated that R1 fell backward in their wheelchair and that the wheelchair did not have an anti-tip feature. Family reported that R1 complained of back and neck pain. Patrick responded that the facility does not provide wheelchairs for residents and that the wheelchair being used was a loaner until R1 could obtain one through his primary physician or purchase one from a pharmacy. Patrick instructed the family on how to request a wheelchair through insurance. The text messages support that the facility provided a temporary wheelchair and informed the family that it was their responsibility to obtain a permanent wheelchair that met R1’s needs.

There was no documentation reviewed showing that the facility refused to allow R1 to use an appropriate wheelchair if provided. The information gathered shows that the facility attempted to accommodate R1 by providing a smaller wheelchair when the original wheelchair did not fit through the bathroom door. The decision not to remove the bathroom doors was related to maintaining privacy for other residents.

Based on interviews and records reviewed, there is not enough evidence to prove that staff failed to provide proper wheelchair accommodations. The facility provided a temporary wheelchair and communicated with the family regarding obtaining a suitable replacement. Therefore, the allegation is unsubstantiated at this time.

A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it.