Complaint Investigation Report

Regarding allegation “Staff did not ensure that resident’s medication was refilled in a timely manner,” it was alleged that facility staff did not order Resident #1’s (R1) antibiotic Daptomycin medication timely. Information gathered during the course of the investigation reflected that Resident #1 (R1) was admitted to facility on 04/19/2024, following discharge from a medical center where they were treated for a bone infection. Upon admission, R1 had a Peripherally Inserted Central Catheter (PICC) and was prescribed the antibiotic Daptomycin, which was to be administered daily by an external Home Health (HH) nurse which continued until 4/25/2024. According to R1, on 04/25/2024, facility staff informed them that their supply of antibiotics was running low. However, when the HH nurse arrived the following day, 04/26/2024, to administer the antibiotic, it was discovered that the supply had run out. The HH nurse immediately advised the facility administrator, to transport R1 to the hospital to ensure they receive their daily dose. Records indicate that the facility logs prescribed medications for residents in care on the centrally stored medication and destruction record to log (LIC 622). However, Daptomycin was not recorded on R1’s LIC 622. Facility administrator stated that since the medication was administered by an external HH nurse rather than facility staff, it had not been recorded on the LIC 622. The facility has been storing the antibiotics for R1 but tracking the medication had not been documented because R1 was receiving HH services. Administrator further stated that R1’s family was expected to refill the antibiotic prescription accordingly and that the HH nurse had been informed about the low supply; however, administrator did not have any supportive documents to provide regarding this agreement. Administrator also could not provide LPAs with HH records pertaining to R1. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that staff did not ensure that resident’s medication was refilled in a timely manner. Therefore, the above allegation “Staff did not ensure that resident’s medication was refilled in a timely manner” is deemed SUBSTANTIATED at this time.