Complaint Investigation Report

Allegation: Staff mismanaged residents’ medications.

On 11/09/2024, Licensing Program Analyst (LPA) L. Alexander conducted interviews and reviewed facility records. During the interview, Witness (W1) stated that Resident 1 (R1) has cancer and is prescribed morphine 15mg. W1 reported that staff document the medication as administered multiple times when it was never actually given. W1 stated that R1 is often in significant pain due to missed doses. W1 further alleged that staff select “Exception” within the QMAR system and note “on hand” even when the medication is unavailable.

LPA reviewed R1’s physician’s orders, which indicated that morphine 15mg is to be administered one tablet by mouth three times daily (9:00 a.m., 12:00 p.m., and 6:00 p.m.). Review of R1’s October 2024 Medication Administration Record (MAR) revealed missing doses on 10/14/24, 10/15/24, 10/16/24, and 10/18/24. Staff 2’s (S2) chart note on 10/16/24 stated, “waiting on pharmacy to deliver not on hand.” The MAR reflects that on 10/14/24, morphine was administered at 6:00 a.m. and 2:00 p.m., and on 10/15/24, at 6:00 a.m. and 10:00 p.m., with the 2:00 p.m. dose omitted.

Allegation: Staff falsified medication administration records.

LPA reviewed Resident 2’s (R2) physician’s orders, which included a narcotic to be administered one pill by mouth every eight (8) hours.