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13 | On 3/17/23 at 10:50 am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up visit to deliver final findings. LPA met with John Kuester, Maintenance Director, in the absence of the Interim Executive Director/Administrator, and explained the purpose of the visit.
On the allegation, “Facility staff mismanaging resident(s) medication,” the complainant’s concern was medications were provided untimely due to medications dropping on the ground.
On 1/27/23, LPA interviewed Resident #1 (R1) about R1’s medications. R1 stated on 12/30/22 around 9am, they heard a crash outside their room and observed pills on the ground from the medication cart. R1 told the med tech they did not want the pills that fell on the ground, and they called the LVN who then brought new pills 1 to 1.5 hours later. R1 stated they typically get their morning medications between 8am and 10am, so if the cart tipped over around 9am and new pills were received 1 to 1.5 hours later, the medication was not given substantially late. Additionally, the physician’s orders for these medications only state to give in the morning and do not denote a specific time. LPA interviewed med tech about the incident. Med tech stated the pills did drop on the floor but new replacement pills were provided within 1 hour to 1.5 hours.
Based on the investigation, the incident appears to have been an accident, and staff tried to provide replacement medications within a reasonable amount of time, therefore the allegation is deemed Unsubstantiated at this time. Exit interview, report given. |