Complaint Investigation Report

Regarding the allegation: Facility staff are not assisting with resident with the self-administration of medication as prescribed.

It was alleged that Resident #1 (R1) did not receive their medications on 11/23/2021, 11/24/2021, and 11/25/2021 and that R1 was observed with ‘unknown’ pills in an envelope. Interviews and record review confirmed that at the time the complaint was received, R1 was receiving a thyroid medication (Synthroid 88mcg) once daily and had a pain medication what was administered as needed (Meloxicam). Interviews revealed that in October 2021, after discussion with R1’s responsible party, the facility requested to add R1’s thyroid medication on cycle with the facility’s preferred pharmacy, Ron’s Pharmacy. Staff claimed that they wanted to do this to avoid any concerns with medications not being delivered in a timely manner and felt that switching pharmacies would make for a smoother transition. Records review noted that on 10/24/2021, the facility placed an order with Ron’s Pharmacy for R1’s thyroid medication. Yet records review further noted that on 11/23/2021, nursing staff documented that Ron’s Pharmacy did not deliver R1’s thyroid medication to the facility, even though the facility requested that the medication to be added on cycle delivery in October 2021. At that time, staff claimed that R1 still had additional thyroid pills, as they placed an order on 10/24/2021. Staff stated that as of 11/23/2021, R1 had not completely ran out of thyroid medication. Staff claimed that prior to a resident running out of a medication, staff ensure that refills are ordered promptly, or they will reach out to a resident’s responsible party or physician to notify them that a medication is running low. After documenting that R1’s thyroid medication was running low, nursing staff confirmed that an emergency order for the medication was placed on 11/25/2021 with Ron’s Pharmacy.

The LPA reviewed the Medication Administration Record (MAR) for R1 and spoke to the nursing staff whom indicated that they assisted R1 with the self-administration of medication for 11/23/2021, 11/24/2021, and 11/25/2021. Interviews with nursing staff revealed that R1 received the last dosage of the thyroid medication the morning of 11/25/2021 and confirmed that they placed an emergency order for the medication on 11/25/2021. Staff claimed that R1 received the medication on 11/23/2021, 11/24/2021, and 11/25/2021 and it was notated in the MAR as administered. Lastly, staff confirmed that R1’s thyroid medication was delivered by Ron’s Pharmacy the evening of 11/25/2021. In addition, interviews and documentation confirmed that R1 was given pain medication (Meloxicam) in an envelope, in an event that R1 stayed with their family overnight. This is a known practice. Staff claimed that R1’s responsible party was aware that R1 had these medications in their possession for this purpose. However, it was revealed that R1 returned to the facility the evening of 11/25/2021 and R1 received their thyroid medication the morning of 11/26/2021.