Complaint Investigation Report

ALLEGATION: Staff mismanaged resident's medication

During the course of investigation for C1 the Department interviewed 3 staff and attempted to interview RP, LPA left voice mails without return calls. LPA received and reviewed MAR, Progress Notes and Physicians fax refusal of Medication Forms which indicates that the Primary Care Doctor and Responsible Party were notified for the dates of January 4, 1/5, 1/6, 1/7 1/8, 1/10, 1/11, and 1/17, 1/18 1/20 and 1/23. Interviewing with S1 revealed that S1 has weekly meeting with RP and S1 would inform RP that C1 was refusing medications including Clozapine, S1 stated that RP asked if S1 notified the Primary Care Doctor S1 stated yes and there were no further instructions given.

During the course of investigation for C2 the Department interviewed 1 staff, 1 client and attempted to interview RP, LPA left voice mails without return calls. LPA received and reviewed C2's MAR, Progress Notes Physicians Report, Medication Order Sheet and Admission Agreement which revealed that C2 was not prescribed a (PRN) pain medication. Interview with S1 revealed that C2 has never requested pain medication. Interview with C2 revealed that C2 doesn't like to take pain medication C2 stated that he reported that C2 needs C2 sleep medication. C2 also stated that C2 doesn't like to stand in line for C2 medication because of pushing and shoving. C2 is currently receiving his sleep medication.