1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Medications not given to resident according to physician's instructions:
On 8/19/2021, the Department interviewed R1's family member (FM). FM stated R1 had doctor's prescription medications to be administered twice per day, but the facility administered R1's medications to R1 at 8:00AM and 4:00PM. FM stated the medications should be administered between 12 hours if the prescription specified twice per day.
On 8/20/2021, LPA interviewed Director of Resident Care Service (DRS). DRS stated caregivers were not allowed to administer medications to residents; only Med Tech or Nurses can administer medications to residents. DRS stated the operation hours of the medication rooms to administer medications to residents were 6:00AM - 8:00AM and 4:00PM - 6:00PM, so the medications will be administered to residents during these time period windows except doctor prescriptions specified the time. DRS stated one of the residents had a doctor prescription specified bedtime 9:00PM, and the facility administered the medications at 9:00PM to resident. DRS stated the facility communicated with R1's family member (FM) to have the doctor to specify the exact time for the medications in the prescription, but the facility did not receive the updated prescription.
Based on the interviews conducted, the facility administered the medications according to doctors' prescriptions. The facility did not receive an updated prescription from the doctor, and the facility followed the facility policy to administer medications to residents.
Lack of supervision resulting in resident wandering from the facility:
On 8/19/2021, the Department interviewed R1's family member (FM). FM stated on 6/13/2021, at 9:00PM, he/she received a phone call from the facility that R1 eloped from the building but was found by staff in facility campus.
On 8/20/2021, LPA interviewed ED. ED stated couple months ago, R1 walked out for fresh air without wearing pendant alarm. ED stated facility staff found R1 disappeared and reported to the facility immediately. ED stated facility staff all searched around and found R1 outside the building but still in the facility campus. Staff took R1 back to building immediately and notified FM. ED stated the facility implemented an action plan to prevent the situation to occur again and sent the action plan to FM. ED stated the facility tried to communicate with FM to discuss how the facility should improve to help residents, but the facility did not receive any response from FM.
Continue on LIC9099-C. Page 3 of 4. |