Complaint Investigation Report

During investigation, LPA L Holmes interviewed clients (C2, C3, C4, C5) on 05/23/23 who stated that staff assist them daily with taking their prescribed medications as ordered by their primary doctors. Staff also assist them in refilling their medications with their pharmacies. Review of clients' centrally stored medication logs and medication administration records show staff administered clients' medications as prescribed.

On 09/27/23, LPA D Panlilio interviewed staff (S1, S2) who stated client (C1) was verbal, ambulatory and not a fall risk. Staff stated they administered C1’s medications as prescribed by her physician. Review of C1’s centrally stored medication logs and medication administration records from 05/2022 until 01/2023 show staff implemented C1’s doctor’s orders as prescribed. One prescription medication (Lisinopril) was discontinued by staff as instructed by C1’s physician dated 11/10/22. Review of C1’s December 2022 records also show she refused to take all her prescribed medications from staff.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff mismanaged resident’s medications resulting in hospitalization and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that staff mismanaged resident’s medication resulting in hospitalization is unsubstantiated.