Complaint Investigation Report

Allegation: The client is not receiving medications as prescribed.

Staff is mishandling a client's medication while in care.

It is alleged client #1 (C1) is not receiving medications as prescribed. The complainant reports (C1) did not receive his medications as prescribed on 08/20/21. An interview with staff #1-#5 (S1-S5) reports that (C1) had refused his evening medications. The staff (S1-S5) claim clients are given reminders over their room intercoms and overhead speakers when it is time for medication distribution. S1 and S5 claim that (C1) was provided reminders through his room intercom at 8:00 pm; 8:30 pm and 9:15 pm. According to (S1 and S5), (C1) responded to all three calls and said he will come to the medication room but failed to show on time and only appeared 20 minutes passed the 9:30 pm cut off time. The facility has posted in several visible areas the Medication Distribution Schedule and House Rules throughout the facility. The House Rules are provided to each client during admission. In the House Rules contains Medication times are at 8:00 am, 12:00 pm, 4:00 pm, and 8:00 pm. Clients must be medication compliant for their health and safety. According to these scheduled times, the clients have one and a half hours to obtain their medications for each time slot. In an interview with (C1), he admitted he was made aware by (S5) that his evening medications were available between 8 pm – 9:30 pm. (C1) also acknowledged the calls by responding to each call. (C1) claims he overslept and that it was only a one-time occurrence. (C1) claims the staff has never denied him access to his medications. (S1-S5) reports when clients are not responsive during the intercom notifications, staff will check in with the client and make special arrangements. In the case of (C1), he was responsive to all notifications and did not require a person follow up. A review of (C1)’s Medication Administration Records (MAR) revealed that (C1) has been provided all his medications timely, accurately and orderly. There’s no indication that (C1) had any missed dosage aside from 08/20/21 which was logged as client refusal. During the tour of the facility, LPA observed the Medication Schedule and House Rule's signs were posted throughout the facility. In an interview (R1-R10) all claim they had no issues receiving medications as prescribed and had no concerns with Medication Distribution Schedule and House Rules mandated by the facility. Furthermore, they all agreed that the staff provides plentiful notifications throughout the day. All clients interview including (C1) reports the staff are responsive to their needs and services and have no problem with medications, or meals services.