Complaint Investigation Report

Allegation: Staff are mismanaging resident's medication.

It is alleged that staff failed to administer medication as prescribed. The complainant reported client #1 (C1's) 2:00 pm daily prescription medication was not dispensed to (C1) as prescribed. The complainant stated (C1's) Sodium Chloride 1 gram tablet scheduled for 2:00 pm on 03/08/24 was not dispensed and not given to (C1). The complainant reported staff #1 (S1) was responsible for this error and did not document or report it to authorized representatives.

On 03/18/24 between 11:10 am - 12:10 pm, the Department audited the Medication Administration Records (MAR) (dated: 03/01/24 - 03/18/24) and revealed there is no electronic log nor the manual log for (C1's) Sodium Chloride 1 gram tablet on 03/08/24 for between 1:00 pm - 2:00 pm. Evidence revealed the medication Sodium Chloride 1 gram tablet was still tacked in the monthly medication bubble pack for (C1) observed by the Department.

On 03/18/24 between 12:10 pm - 02:20 pm (2) out of (6) staff #1-#6 (S1-S6) were interviewed by the Department were aware of the error. (S1-S2) admitted knowing about the medication error not being dispensed on 03/08/24. (S1) notified (S2) that (S1) discovered prescribed medication for (C1) on 03/08/24 was not dispensed. (S1) reported this happened during morning to afternoon staff shift change. (S1) reported that it was the morning LVN staff's responsibility to dispense the afternoon medication for (C1) before the end of the shift. (S1) stated there was no communication that the LVN staff on 03/08/24 that the afternoon medication for (C1) was not given. (S1) did not follow up or audit the electronic (MAR) until 03/13/24 when (S1) noticed the medication was still in the bubble pack for (C1) and reported it to (S2). (S2) claimed to have reported it to the Program Director staff #4 (S4) on 03/13/24. (S4) denied having any knowledge of the matter and did not report the incident. (S3-S4) both responsible for assisting clients with medications, also did not recognize the medication error on 03/08/24. Although there have been some medication errors in the past, Area Manager staff #6 (S6) was unaware of the medication error on 03/08/24 and none of the care staff reported it. This incident has not been reported to Community Care Licensing, Harbor Regional Center, or Primary Care Physician, according to (S1-S6).