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25 | Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 09/05/2024, stemming from subsequent complaint investigation conducted on 09/05/2024. LPA Ramirez was greeted by Wellness Director Cassandra Crowley and explained the purpose of the visit.
Case Management-Deficiencies findings:
LPA Ramirez received four (4) Unusual Incident/Injury Reports (LIC 624) dated 06/21/2024 & 08/06/2024. R1 has a physician’s order for Keppra (250mg) which is to be administered twice daily. On 06/21/2024, staff assisted R1 with the administration of prescribed Keppra (250mg) during PM medication pass and an additional 500mg in error. R2 has a physician’s order for Olanzapine (2.5mg) which is to be administered in the evening. On 06/21/2024, staff assisted R2 with a double dose of prescribed Olanzapine (2.5mg). R3 has a physician’s order for Lorazepam (1mg) which is to be administered as needed every 6 hours. On 08/06/2024, staff assisted R3 with the administration of prescribed Lorazepam (1mg) at 2pm, 4pm and at 9pm. R4 has a physician’s order for Lorazepam (0.5mg) which is to be administered as needed and not exceed one dose in 24 hours. On 08/06/2024, staff assisted R4 with the administration of prescribed Lorazepam (0.5mg) during the AM medication pass and again during the PM medication pass.
On 08/05/2024, the facility suspended two (2) medication technicians (S1 & S2) while an internal investigation was conducted by the facility. On 08/19/2024, S1 & S2 were terminated from their positions at the facility. Per Wellness Director Cassandra Crowley, all medications technicians have started re-training.
Based on records reviewed and interviews conducted during case management visit, staff that assisted residents with the self-administration of medication were not competent in providing the services necessary to meet the residents’ needs, which possess an immediate health and safety risk to residents in care.
One (1) type A deficiency is being cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email.
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