Complaint Investigation Report

ALLEGATION #7: Staff dispensed wrong medication not prescribed to resident.

It is alleged that the facility staff administered incorrect medications that were not prescribed for Resident #1 (R1). Reports indicate that medications intended for other residents were given to (R1) when (R1's) prescriptions were not refilled. The specific dates and types of medicines involved have not been provided. No further details are available regarding this matter.

On March 11, 2025, between 10:00 AM and 11:45 AM, the Department interviewed residents identified as Resident #2 to Resident #5 (R2-R5). Four (4) out of the four (4) residents were unable to validate this claim. (R2-R4) expressed that the staff closely observes the medications for each resident. They have never received incorrect medications or experienced issues with refills.

On March 11, 2025, between 10:30 AM and 1:00 PM, the Department interviewed staff identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) claim this accusation is false. (S1-S2) claimed to follow the Seven Rights of Medication Administration to ensure safe and effective medication delivery to prevent medication errors and protect residents' safety. (S1) indicated that (R1) is alert and can recognize the medications given to (R1) by the staff. (R1) is also able to administer (R1's) meds and store their own medications as ordered by (R1's) physician.

On April 17, 2025, between 2:30 PM and 3:30 PM, the Department interviewed Resident #1 (R1). (R1) communicated a clear understanding of (R1's) medication needs, stating that while (R1) may not be familiar with the specific types of medications being dispensed, (R1) is committed to taking only those prescribed by (R1's) doctor. Moreover, (R1) expressed independence by indicating (R1's) ability to manage and store (R1's) own medications. However, (R1) emphasized a preference for staff assistance with this task.

The Department reviewed (R1’s) Physician’s Report LIC 602 (dated 05/24/23), the Preplacement Appraisal Information LIC 603 (dated 08/08/24), and the Appraisal/Needs and Service Plan LIC 625 (dated 08/08/24). The Department confirmed that (R1) can administer and store its own prescription medications, with staff assistance provided as needed.