Complaint Investigation Report

Staff do not give residents’ medication as prescribed - UNSUBSTANTIATED

It was reported that medications are not being dispensed properly.

LPA review of EMAR for Resident 1 (R1) revealed that R1 had been prescribed Quetiapine (Seroquel) 100 mg on 11/23/2020, 1.5 tablets were to be taken by mouth at bedtime. Also, on 11/23/2020 R1 was prescribed Quetiapine (Seroquel) 100 mg, 1 tablet to be taken in the morning. According to the EMAR both of these prescriptions were discontinued on 6/16/2023. On 6/16/2023 a new prescription for Quetiapine (Seroquel) 50 mg was started and dispensed 2 tablets once per evening.

LPA reviewed physician’s orders for R1 for prescriptions for Quetiapine (Seroquel). 11/23/2020 Order summary: Quetiapine Fumarate Tablet 100 MG Give 1 tablet by mouth in the morning for agitation supervised self-administration AND Give 1.5 tablet by mouth at bedtime for agitation supervised self-administration. 06/16/2023 Order summary: Quetiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate). Give 2 tablets by mouth in the evening for depression.

4 of 4 staff stated they use a computer with an EMAR to ensure they are dispensing the correct medication to the correct resident. They check the resident photo, name, and prescription before dispensing.

Administrator stated the facility uses the point click care computer system which has the resident’s photo and bubble pack medications. Staff compares the order on the screen to the bubble pack and photograph and double check that they match.

It was determined that the facility dispensed medications as prescribed by R1’s physician. Staff use the EMAR to ensure they are dispensing medications to residents properly. This allegation is unsubstantiated.