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32 | The to-be-discarded medications per S1 would have been stored in one of two smaller safes and the black cabinet. Based on observation with S1, no medications that needed to be destroyed were observed in the locked areas of the office during the visit. One of three staff indicated staff are not aware and would not have access to medications that needed to be destroyed to avoid confusion with the medications that need to be administered. The remaining two staff indicated during interviews not knowing if the medications that needed to be destroyed were safeguarded on site as they only have access to current routine and pro re nata (PRN) medications. Three of three staff and three of four clients denied observing S1 using clients' medications.
Regarding the allegation, Staff mishandled client's medications, it is alleged that a client did not receive their morning medication and all clients were missing their pro re nata (PRN) or "as needed" medications. LPA reviewed all routine and PRN medications prescribed for all four clients for June and July 2026. Based on LPA's review, routine medications were administered as prescribed and documented appropriately on the Medication Administration Record (MAR) for June and July 2026. Of the four clients, only two had PRN medications prescribed. Of those two clients, only one had been receiving PRN medications during the review period, and the administration was documented correctly on the MARs. One of four clients, confirmed the allegation as the client reported receiving medication at the incorrect scheduled time. The client's bedtime medication was mistakenly administered during the evening (PM) medication pass. The error was allegedly immediately recognized by staff, and the correct evening (PM) medications were subsequently administered. However, there was no evidence to verify or confirm that the medications had been switched and given at the wrong time. Three of four clients and three of three staff interviewed did not corroborate with the allegation.
Regarding the allegation, Staff consumed drugs during work hours, impairing their ability to provide adequate care and supervision presenting a risk to clients, it is alleged that Staff #5 (S5) and Staff #6 (S6) smoked marijuana in a ventilated bathroom neglecting clients which was reported to S1 and resulting Staff #7 (S7) to quit. Five of five staff and one individual denied witnessing S5 and S6 smoking on the job. However, two of four clients confirmed staff showing signs of being impaired. One client observed the eyes of S5 or S6 appearing red during off hours while another client reported another staff smelling like marijuana during their shift. Both clients reported not witnessing S5, S6, or other staff smoking marijuana during their shifts. Based on the investigation, there was insufficient evidence to corroborate the allegation. |