The Department investigated the allegations that the resident was not provided prescribed medication and that the facility was falsifying medication charts. It was alleged that Resident #5 (R5) went into seizures due to staff not ordering the medication. It was reported that staff would mark the Medication Administration Record (MAR) that the medication was given when it was not. R5 was not able to be interviewed since they no longer resided at the facility at time of visit. LPA reviewed Unusual Incident Reports and noted a seizure incident that occurred on August 23, 2022. It was noted on the Unusual Incident Report, submitted to the Department on August 24, 2022, that the resident took the anticonvulsant medication daily. LPA reviewed the MAR and noted that the anticonvulsant medication was given daily and initialed by various medication technicians (med techs).

LPA interviewed one of one staff and one of one witness who had knowledge of the incident. One of one staff denied the allegation. One of one witness stated the name of a former med tech who would falsify records and initial given medications. LPA confirmed the med tech named by the witness was the med tech initials on the Medication Administration Record for the incident on August 23, 2022. LPA was unable to interview the MedTech in question. When LPA asked the witness about the particular incident, the witness could not remember this happening. LPA interviewed one of one staff member present who could not recall the specifics of the incident. Thus the allegations that: Facility did not ensure resident was provided prescribed medication and Facility falsifying medication chart are Unsubstantiated.(Cont'ed on LIC 9099-C1)

It was alleged that Unqualified staff were administering insulin to residents. LPA interviewed three of three staff members who denied this allegation. LPA obtained the facility policy regarding injection administration. Only a nurse, such as the licensed vocational nurse (LVN) can administer medications. The facility employs a LVN; as well as the Health Services Director (HSD) who both have a valid LVN license. The allegation stated that med techs were administering insulin to residents. LPA reviewed four of four resident Medication Administration records who received insulin at the time of complaint received. Only one of the four residents still resided at the facility. LPA interviewed Resident #1 (R1) who stated they self-injected their insulin and that, for four to five months, staff did assist with injections. R1 could not confirm if the staff member was a nurse or a med tech, but that R1 prefers to self-inject themself.

LPA attempted to interview three of five med techs from 2023. Three were no longer employed by the facility and did not have working phone numbers or emails. Two of the five med techs interviewed denied the allegation. LPA also reviewed five of five staff electronic files which include training and in-services. Staff members’ training records document five of five staff completed medication administration training. Thus the allegation that unqualified staff were administering insulin to residents was Unsubstantiated.

Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that: Staff neglect resulting in death of resident, Facility did not ensure resident was provided prescribed medication, Facility falsifying medication chart, Facility not responding to resident's call light in a timely manner and Unqualified staff administering insulin to residents are Unsubstantiated.

An exit interview was conducted with Hanofi Edogiawerie, Health Services Director and a copy of this report was provided to the facility.