Complaint Investigation Report

The investigation reveals the following: Regarding “Staff mismanaged resident's medications”. It is alleged that the facility removed R1’s prescribed Omeprazole and replaced it with a facility-provided version of the medication. It was found that R1 began receiving Omeprazole from the facility pharmacy after the Omeprazole they had moved in with ran out. This caused a change in the manufacturer and the medication's color, which alerted R1. During the file review, LPA determined that R1 consented to using the facilities' pharmacy rather than the pharmacy they had before moving in. R1 stated they don’t want to make any changes to the medication and will continue taking the medication provided by the facility. The administrator and 2 out of 2 staff stated they have given the medication as prescribed and can use another pharmacy if this is what R1 wants. W1 stated that both forms of Omeprazole have the same effect and that they have educated R1 on the topic. 13 out of 14 residents stated they either receive assistance with their medication or take it independently and have no issues with the facility.

The investigation reveals the following: Regarding “Staff did not communicate with the resident's responsible party of medication changes”. It is alleged that the facility has been providing the resident with a facility version of their prescribed medication without notifying the resident's responsible party. The administrator and both staff members stated that R1 does not have a Power of Attorney and that they are their own responsible party. They further stated there were no changes in the medication. R1 stated they were not informed of the medication change. File review confirmed that R1 is their own responsible party and that there were no changes to the medication. LPA also confirmed that R1 consented to using the facility pharmacy. 13 of 14 residents stated that the facility always updates them on any changes to their care.

Based on LPA's interviews, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Administrator Mark Padilla, and a copy of this record was provided.