Vista Prairie at Garnette Gard.

Finding: Substantiated, individual responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The alleged perpetrator (AP) financially exploited five residents when she diverted controlled substances including opioid pain medications. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. The investigation identified a pattern of documentation indicative of drug diversion for four out of the five residents reviewed extending over a three month period. The investigator conducted interviews with facility staff members, including administrative staff and unlicensed staff. The investigator interviewed three residents who still resided at the facility. The investigation included review of five resident records, facility internal investigation, facility incident reports, personnel files, staff schedules, law enforcement report, related facility policy and procedures. Also, the investigation included an onsite visit. The investigation reviewed residents’ medical records over a four month period and referred to below as months #1 through month #4. The AP The AP worked at the facility as an unlicensed caregiver whose duties included medication administration. The AP’s job duties gave her access to residents’ controlled medications. The facility’s schedule and payroll indicated the AP primarily worked evening shift. During random audits of prescribed controlled substances, the facility found discrepancies in the AP’s medication passes for five residents. The discrepancies included the following controlled substances as tracked in the facility’s narcotic book: Lorazepam (a benzodiazepine for anxiety)  Norco (a combination of hydrocodone, an opioid, and acetaminophen for pain relief)  Oxycodone (an opioid for pain relief)  Tramadol (a synthetic opioid pain reliever)  The investigation identified a pattern which indicated the AP diverted from four of the five residents identified in the random audits of controlled substances over the course of three months. Near the end of month #3, the AP no longer worked at the facility. Resident #1 The resident #1 ‘s diagnoses included anxiety disorder and bipolar disorder. The service plan for resident #1 included assistance with medication administration. The electronic medication administration record (EMAR) indicated the resident was prescribed lorazepam 0.5 milligram (mg) one tablet by mouth every two hours PRN (as needed). During month #3 the narcotic book indicated the AP removed PRN Lorazepam from resident #1’s supply on one occasion. However, there was no corresponding record of administration in the EMAR. The investigation did not identify a pattern of documentation of drug diversion regarding resident #1. Resident #2 The resident #2 diagnoses included dementia and restless legs syndrome. The service plan for resident #2 included assistance with medication administration. During the second half of month #1 the EMAR indicated resident #2’s medications included: Norco one tablet every eight hours  Norco one tablet daily on during the evening shift  During the second half of month #1 the EMAR indicated the AP documented giving PRN Norco 10 out of the 11 times it was administered the whole month. The same document indicated resident #2 did not require PRN Norco on most days the AP was not working. Although a scheduled Norco dose was scheduled during the evening shift, the EMAR indicated all of the PRN doses administered by the AP were time stamped for the evening shift. On the last day of month #1 and continuing for all of month #2 the EMAR indicated the APs medications included the following medication: Norco one tablet by mouth every two hours PRN  On the last day of month #1, the EMAR indicated the AP documented administering PRN Norco three times. The same documented the AP was the only medication passer to give this medication on this day. During month #2 the EMAR indicated the AP documented giving PRN Norco approximately 90 times. The same document indicated all other medication passers documented giving PRN Norco a total of seven times combined for all of month #2. During month #3 the EMAR indicated resident #2’s pain medications were changed and included: Oxycodone 5 mg one tablet by mouth every six hours, which was scheduled at 8:00 a.m.,  12:00 p.m., and Bedtime Oxycodone 5 mg one tablet by mouth every two hours PRN  During month #3 the narcotic book indicated the AP was the only medication passer to remove the PRN oxycodone for a total of eight times. The EMAR included six occasions during month #3 the AP documented administrating the PRN oxycodone. During month #3 the facility conducted random audits and identified discrepancies regarding resident #2’s controlled substances, which included two instances the AP documented in the narcotic book removing oxycodone from resident #2’s supply, but the AP did not document administration of the oxycodone in the EMAR. The last day the AP documented passing medications for resident #2 occurred during month #3, which was also the last day any medication passers documented giving PRN oxycodone that month. During month #4, the AP did not work at the facility. The EMAR indicated resident #2 did not receive PRN oxycodone during month #4. Resident #3 The resident #3 lived in an assisted living facility and was diagnosed with low back pain and rheumatoid arthritis. The service plan for resident #3 included assistance with medication administration. The EMAR indicated resident #3’s medications included: Oxycodone 5 mg one tablet at bedtime  Oxycodone 5 mg one tablet three times a day PRN with instructions to only give  between 5:00 a.m. to 3:00 p.m. and to not give a second dose at bedtime During month #1 the EMAR indicated the PRN oxycodone was administered 16 times with the AP documenting 12 of those times usually at the beginning of the evening shift. During month #2 the EMAR indicated the AP was the sole medication passer to document giving the PRN oxycodone. The AP documented this more than 15 times. During month #3 the EMAR indicated the PRN oxycodone was administered 12 times with the AP documenting 11 of those times usually at the beginning of the evening shift. During month #3 the narcotic book indicated the AP documented removing PRN oxycodone from resident #3’s supply 16 times on one page. The EMAR covering the same time indicated the AP documented administrating six of those occasions. During month #3 the facility conducted random audits and identified discrepancies regarding resident #3’s controlled substances, which included multiple instances the AP documented in the narcotic book removing oxycodone from resident #3’s supply, but the AP did not document administration of the oxycodone in the EMAR. The last day the AP documented passing medications for resident #3 occurred during month #3, which was also the last day any medication passers documented giving PRN oxycodone that month. During month #4, the AP did not work at the facility. The EMAR indicated resident #3 did not receive PRN oxycodone during month #4. Resident #4 Resident #4’s diagnoses included chronic left knee pain. The service plan for resident #4 included assistance with medication administration. The EMAR indicated resident #3’s medications included: Tramadol 50 mg one tablet three times a day PRN  During month #1 the EMAR indicated PRN tramadol was documented as administered approximately 25 times. All but two of these occasions was documented by the AP. During month #2 the EMAR indicated the AP was the sole medication passer to document giving the PRN tramadol. The AP documented this 15 times. During month #3 the EMAR indicated the AP was the sole medication passer to document giving the PRN tramadol. The documented this more than 20 times. During month #3 the facility conducted random audits and identified discrepancies regarding resident #4’s controlled substances. The narcotic book indicated the AP documented removing PRN tramadol from resident #4’s supply. The audit found more than 10 occasions the AP documented removing PRN tramadol in the narcotic book for which there was no corresponding EMAR documentation during the months #2 and #3. The last day the AP documented passing medications for resident #4 occurred during month #3, which was also the last day any medication passers documented giving PRN oxycodone that month. During month #4, the AP did not work at the facility. The EMAR indicated resident #4 did not receive PRN tramadol during month #4. Resident #5 The resident #5’s diagnoses included chronic pain.