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32 | Regarding the allegation that staff do not keep medications locked, making them accessible to residents: it was alleged that medications are not locked and C1 stole and self-administered a dose of C2’s cough syrup. LPA inspected the facility and observed the medications to be locked in a medication cart in the living room. LPA reviewed the facility’s communication log from January 2024 to the present and noted the following: an entry on March 13, 2024 stating that a new medication cart will be assembled; and an entry on April 2, 2024 stating that someone will come that day to “fix” the medication cart. LPA reviewed the facility’s flow sheets for C1 and C2 from March 1, 2024 to the present, which document the daily routine and incidents for these clients, and did not obtain information corroborating this allegation. LPA interviewed AD and three staff who denied the allegation and stated that while the medication cart was broken the medications were properly stored in another locked location, but also reported there was an incident recently where C1 had asked a staff to give them another client’s medication, that C1 was manipulative and wanted to get this staff fired, that C1 did this in order to get the staff fired, but that C1 was never actually given another client’s medication. LPA interviewed three clients, two of whom did not corroborate the allegation. C1 denied that medications were unlocked and that they had asked the staff for another client’s medication, but offered a conflicting story that the staff in question gave them C2’s cough syrup on their own accord but that they had poured it out because they knew they were not supposed to take another client’s medications. Per AD, this staff was terminated shortly after this incident due to not having the required skill set for the position. LPA reviewed the facility’s Medication Administration Records for March 2024 and did not obtain information corroborating the allegation. LPA reviewed C1’s Individual Program Plan which states C1 has a history of habitual lying. The investigation revealed three conflicting versions of the alleged incident and no corroborating documentation was obtained. The information obtained is conflicting.
Regarding the allegation that staff do not keep knives locked, making them accessible to residents: it was alleged that sharp knives and a lighter are not locked and are left in non-lockable drawers or out in the open. LPA inspected the facility and observed the knives and a lighter to be locked. LPA also confirmed that all toxins were properly stored. LPA interviewed AD, three staff, and three clients and did not obtain information corroborating this allegation.
Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegation are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. |