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32 | RCD was unable to provide the name of the staff member that R1 left the facility with. R1’s only visitor at the facility, was their responsible party. RCD stated that per information received regarding positive toxicology report, R1’s entire room, clothing, furniture, shoes, bathroom and mattress was searched and there, were no medications or substances located.
LPA’s review of R1’s Physician Report revealed R1’s primary diagnosis was Aphasia, Parkinson’s Disease, Dementia, Sick Sinus Syndrome and Restless Leg Syndrome. A review of the Medical Administration Record (MAR) for R1 indicated that all medications for the period of 3/11/20 thru 3/29/20, were administered per physician’s orders.
According to R1’s medical records, it was initially noted that there were no medications that R1 was currently taking that would indicate a positive screen for Amphetamines; however, the discharge notes indicated that medication Selegiline could have possibly caused the positive toxicology report. Medical records also revealed that R1’s medication regiment for the period of 3/29/20 thru 5/11/20 was changed several times during R1’s hospitalization. Per medical record notes, R1’s aggressive behavior toward staff and agitation occurred multiple times throughout their stay at the hospital.
Information received revealed that R1’s responsible party was concerned about medications Selegiline and Lexapro, which R1 was administered after suffering a stroke in 1/31/2020. Their concern was that the reported side effects of these medications are paranoia and aggression.
The Department’s investigation found there is insufficient evidence to determine that facility staff administered incorrect medication to resident resulting in hospitalization. Interviews conducted with staff, responsible party, outside sources, and review of medical and facility records provided no conclusive evidence to support the allegation.
Based on review of records including medical and facility, information from outside sources and interviews conducted, allegation is Unsubstantiated. Although the allegation may have occurred or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.
An exit interview was conducted with Kimberly Santillian, Executive Director and Sheliah Sanchez, Resident Care Director, the Licensee’s Rights (LIC 9058 01/16), Confidential Names List (dLIC 811) along with a copy of this report was provided to Kimberly Santillian, Executive Director and the signature on this form confirms receipt of these rights.
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