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32 | (Continuation of LIC9099)
A tour of the panel was conducted, and they demonstrated what sounded on the panel and where the panel indicated the issue was. Engineer staff provided LPA with the room’s log to where the issue was located. In review of the log, the description verified that the smoke alarm was being triggered each time that the resident would call for staff assistance. In review of the invoice for the services that were performed, it demonstrated that the panels wires had a ground fault and repairs were made to the nurse switches to that specific room. Based on the information obtained, there is sufficient evidence to support this allegation.
It was said that the staff provided resident #1 (R1s) medication daily when their primary care physician (PCP) had discontinued a medication from a daily medication to a pro re nata (PRN). In review of the facility’s Medication Administration Record (MAR) the medication that which was incorporated as a routine medication order was dated March 15, 2022. According to the routine medication order, the medication was discontinued on March 26, 2022. In review of the same month’s PRN medication orders listed the same medication on R1’s MAR as a PRN and provided to R1 as a PRN for the dates of March 15 – 19, 22, 27 – 29, and 31, 2022. According to the Discontinuation Orders, this medication was discontinued twice. The first on 3/04/2022, but the MAR indicated that it was not due. The second time this medication was discontinued was on 03/25/2022, which MAR shows an X for not due. This medication was issued in March 2022 as R1's MAR for December 2021, January 2022, and February 2022 did not have an order for this medication. According to the primary care physician's (PCPs) order there was an order change for this medication on 03/24/2022 from taking one tablet in the morning to taking one tablet every eight hours as needed. This was reflected on the MARs routine med order, and not to exceed 4 grams per day from all sources. This medication reflected on the PRN medications list as being administered a second time that started March 15, 2022, but did not exceed the dosage allowed.
In further review of R1s, MAR, there was one other medication that was incorrectly discontinued. The medication was discontinued prior to the discontinuation date. The medication was not administered on 3/03/22 – 03/05/22 and was marked as discontinued on 3/05/2024 on the MAR. According to the annotation on the order it showed that the discontinuation date was on 3/04/2022. According to the Discontinuation orders, the discontinuation date is 03/04/2022.
It was additionally said that the medications were being provide incorrectly to residents and there were medications that were missed for residents on/or around September 2022. In review of randomly selected residents MARs for September 2022 they indicated that there were discrepancies that the facility annotated for many medications unable to verify the medications and the medications were not administered. Although there were no annotations indicating the incorrect medications were provided to a resident on the MAR, there is information regarding the medications that were missed.
(Continuation on LIC9099-C) |