Complaint Investigation Report

Allegation: Staff did not ensure correct medications were dispensed to resident. It is alleged that S5 gave R1 another resident's medication.

According to SIR dated 07/27/2024, R1 was administered incorrect medication on 7/26/2024 at approximately 9:00 PM

LPA Interviewed eight (8) staff and six (6) of eight (8) staff corroborated the allegation. One staff did not know and could not answer and S5 could not answer LPA questions during phone contact and stated S5 was too busy. S1, S2, S3, S6, S7, and S8 admitted the medication error and One (1) of eight (8) residents was able to corroborate the allegation. W#1 who is family member also corroborated the allegation. On 7/26/2024 at approximately 9:00 PM, S5 provided the wrong medication to R1. The error occurred because S5 mistook one resident for another because both residents shared the same last name. There is enough evidence to substantiate this allegation

Allegation: Staff did not ensure medications were dispensed in a timely manner. It is alleged that one staff forgot to provided medications to resident at one night.

LPA interviewed eight (8) staff and six (6) of (8) staff denied the allegation. S3 admitted that this occurred. S8 who was responsible to administer medications to resident one night stated S8 forgot and called niece immediately to notify her and immediately administered the medication that night. Medication were administered late on at least one night according to S8 statement. LPA interviewed Eight (8) residents and seven (7) of (8) residents could not corroborate the allegation. There is enough evidence to substantiate this allegation.

The facility admitted the errors and stated they took corrective action that included additional training of staff.

Based on LPA's record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation are SUBSTANTIATED.

Exit interview and copy of report, 9099-D and appeal rights provided to administrator Lisa Pham.