Complaint Investigation Report

The investigation revealed the following: Regarding allegation: Resident(s) not being provided their prescription as prescribed. It is alleged an unqualified staff was dispensing medication resulting in resident given the wrong medication. Interviews with residents revealed 6 out of 7 residents interview stated that a Med-tech provides the medication to residents and 1 out of 7 residents did not know if staff was trained to provide medication to residents. 4 out of 7 residents stated to have never miss a dose of medication or been given the wrong medication. 2 out of 7 residents stated to have missed a dose of their medication recently, and 1 out of 7 residents stated to "seldom" miss a dose in the past. Interviews with staff revealed 5 out of 5 staff interview stated to not have heard residents state missing medication or of medication errors. On 4/4/22 LPA reviewed medication for R1,R2,R3,R4,R5,R6,R7 which consisted of reviewing the medication sheet which lists all prescribed and PRN medication and comparing it to the bubble packs or medication bottles, checking initials marked on dates for medication provided by Med-Tech and ensuring the medications listed are available. No errors were observed.

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.

Regarding allegation: Resident(s) medications not being refilled in a timely manner. It is alleged staff did not have nor had requested residents medications prior to running out. Interviews with residents revealed 4 out of 7 residents have always have their prescription available and filled, 2 out of 7 residents stated to either their prescription not filled timely or had been missing at the time of providing dose, and 1 out of 7 residents stated their social worker ensures prescription is filled. Interviews with staff revealed 3 out of 5 staff stated to not have heard of prescription not available at facility, 2 out of 5 staff stated resident had complaint of not having prescription available or prescription was not filled timely, however the prescription was not filled due to change of pharmacy by resident. 1 out of 5 staff interview stated that the pharmacy did not filled a prescription for resident due to communication between the physician and the pharmacy, and facility reach out to assist with getting the prescription filled out. Documents review revealed medication sheet noted a medication had finished on 2/25/22 and 3/27/22 for R7 and there were (0) zero refills available, a fax communication transcript was reviewed dated 2/14/22 regarding requesting refill to a different pharmacy and Med-tech notes regarding same medication for March 25th and 26th showed staff noted a follow up with physician for refill of medication.

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, (CONTINUED ON LIC 9099C)