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32 | investigation. Throughout the course of the investigation, LPA Dulek interviewed staff and other relevant parties during unrelated facility visits and LPA reviewed relevant documents. The following was then determined:
Allegations: “Resident developed a septic infection while in care” and “Unqualified staff providing wound care services:”
It was alleged that Resident #1 (R1) had developed a septic infection due to untrained medication technicians providing wound care for R1. Staff interviewed all indicated they do not do any wound care, only basic first aid, such as placing a bandaid for a resident. Additionally, interview revealed that R1 had home health care for the wounds on their heels, which was confirmed through record review. During the investigation, LPA discovered 2 (two) additional residents who were utilizing home health services to provide wound care. Interviews revealed that R1 did not have a septic infection, nor could staff recall any other resident with a septic infection. Based on interview and record review, at this time, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegations that “resident developed a septic infection while in care” and “unqualified staff providing wound care services” is deemed UNSUBSTANTIATED at this time.
Allegations: “Staff did not administer medications to residents” and “Staff stealing residents’ medications:”
The complaint alleges that staff stole narcotic medications prescribed to residents instead of administering the medications to the residents. The complaint further alleges that when narcotics were missing, staff were asked by management to sign missing signatures on controlled substance log. Interviews revealed that residents do get their medications regularly as prescribed, as well as PRN medications as needed upon request. All staff interviewed indicated that they only sign off on medications they have administered and have not been asked to sign something when they did not personally administer a medication. Interviews revealed that there have been no reports of staff stealing medications and no medications “missing.” Controlled substance logs reviewed appeared consistent with medication administration records. Based on interview and record review, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations that “staff did not administer medications to residents” and “staff stealing residents’ medications” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C
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