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32 | Continued from LIC 9099
Regarding allegation of “Staff mismanage resident’s medication” it was reported that during a routine hospice visit, the Kaiser Hospice Registered Nurse (RN) observed that liquid morphine drawn from the medication bottle appeared altered, noting a difference in color and a fruity odor. Interviews conducted with family members stated that R1 receives hospice care and 24-hour care from several private caregivers in addition with support from facility's care staff. They expressed satisfaction with services provided by this facility. Family members revealed that R1’s medication are not stored, safeguarded, or managed by the facility. Interview with the RN revealed that R1 has been receiving hospice services at this facility for approximately two (2) years. The RN stated that throughout that time there have been no previous concerns regarding missing or tampered medications and confirmed that facility staff have not been responsible for storing, safeguarding, refilling or administering R1’s medication. Interviews with the ED and the Director of Health Care Services confirmed that R1’s medications are managed and dispensed by Kaiser hospice personnel and are not maintained by the facility and/or facility staff. Adding, that facility has a list of medication on file for R1; however, facility does not maintain records of medication administration or dosages dispensed for R1. Based on interviews conducted, all parties consistently reported that facility staff are not responsible for the storage, safeguarding, or administration of R1’s medication. Records reviewed revealed that R1 receives 24 hour one-to-one (1:1) care provided by caregivers hired by the family. Medication management responsibilities are overseen by R1's designated Power of Attorney (POA). There was insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff mismanage resident’s medication” is deemed unsubstantiated at this time.
Exit interview conducted. No citations issued. A copy of this report was provided.
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