Complaint Investigation Report

Allegation: Facility staff gave resident incorrect amount of medication. Per Administrator interview, R-2 was admitted to this facility on 08/04/22 in the evening. Per Administrator, upon R-2’s arrival, Administrator noticed (2) bottles of Quantiapine Fumarate (both written on 07/20/22) (1) bottle indicated 50mg “take 1 tablet by mouth twice a day” and the other bottle indicated 100mg “take 1 tablet by mouth once daily”. Per Administrator, a request for clarification on Quantiapine Fumarate dosage was sent to R-2’s Physician prior to administering this medication on the same day of admission. Per documentation reviewed, R-2’s Physician clarified the order on 08/05/22 (as R-2 was admitted the evening on 08/04/22) for Quantiapine Fumarate to be administered 50mg twice per day. Per interview, R-2 was not given the incorrect amount of medication. Interview and collected documentation does not corroborate this allegation.

Allegation: Resident sustained unexplained bruising while in care. Per Administrator interview, R-2 was admitted to this facility on 08/04/22 in the evening. Per Administrator, upon R-2’s arrival, Administrator noticed R-2 of having bruising on the arms due to a fall that R-2 sustained while residing at home. Per Administrator, the bruising was not reported as Administrator was informed that R-2 had fallen at home and sustained bruising. Administrator also provided a copy of hospital discharge orders with education information on “fall prevention in the home, adult” that was provided to R-2 upon discharge from the hospital. Interview conducted and documentation reviewed does not corroborate this allegation.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to the Facility Administrator.