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32 | The complaint alleges that the facility staff did not assist Resident #1 (R1) in obtaining medical care nor did the facility assist the resident with self-administration of prescribed medications, both of which led to R1’s worsening medical conditions and subsequent hospitalization. Record review revealed that R1 had an extensive medical history, however R1’s medical conditions were managed through use of prescribed medications. Interviews revealed that R1, among many other residents, use the facility-contracted pharmacy provider. Around October 2022, the facility began to change contracted pharmacy providers to Concierge RX Pharmacy. The new pharmacy had a policy requiring residents to keep a card on file for all potential payments. R1 was one of approximately 8 (eight) residents who did not have a card on file. Interviews revealed that the pharmacy contacted these residents and/or their responsible parties to rectify the payment situation, and all residents’ payments except for R1’s were resolved. Interviews also revealed that the pharmacy attempted to contact R1’s brother, however, it was confirmed R1 was their own responsible party. It is unclear why R1’s brother was contacted, but interviews revealed facility staff did not directly assist the resident in rectifying the payment method. Beginning in November 2022, Concierge RX Pharmacy filled medication orders for residents residing at Aasta Assisted Living, including R1. However, R1 still did not have a credit card to keep on file, so the pharmacy did not deliver R1’s medications for December 2022. Facility staff indicated they sent faxes to R1’s primary care physician to inform the medical provider that R1 had not received their medications, however the facility’s fax machine did not provide confirmation the faxes were sent nor received. Interview with R1’s primary medical care provider revealed the facility staff never contacted the physician via telephone and no faxes were received at the medical office. R1’s physician was unaware R1 had not received medication in December 2022. Review of R1’s Medication Administration Record (MAR) revealed that R1’s MAR was marked as “med not available” on 12/01/2022, but was initialed as administered on 12/02/2022 and the entry for 12/03/2022 was empty. Interview revealed that R1’s MAR was incorrectly marked and R1 did not have any medications on any date in December 2022.
By 12/22/2022, it was observed that R1 wasn’t feeling well and was experiencing shortness of breath. On this date, facility staff offered to take R1 to the bank to request a debit card, however R1 wasn’t feeling well and declined an outing to the bank. Although R1 was experiencing shortness of breath and difficulty breathing, facility staff did not call 9-1-1 nor was additional medical care requested for R1. On 12/23/2022, facility staff did take R1 to the bank to order a debit card, however, at this point R1 had already been without medication for 23 days since 12/01/2022. Over the next week, R1’s difficulty breathing worsened and on 12/31/2022,
Report Continued on LIC-9099-C |