Complaint Investigation Report

Allegation: Staff threatened to overmedicate resident in care

The details of the complaint alleged that facility staff threatened to overmedicate (R#1) while in care.

On April 23, 2026, at approximately 10:00 a.m., during the records review, the Department observed copies of the facility staff Inservice training documents for the year 2026. The Department noted that facility staff had completed a series of training courses, including training on residents’ rights and how to treat residents with dignity and respect.

On April 23, 2026, during an interview with the facility administrator (A#1), the Department asked (A#1) to explain the facility’s expectations for staff communication regarding medications and how the facility addresses any statements that could be interpreted as threatening or inappropriate. (A#1) stated that facility staff assist residents only with their regularly prescribed medications. Staff inform residents when it is time for medication, and if a resident refuses, staff document the refusal and do not force the resident to take the medication. (A#1) further stated that for medications such as morphine, facility staff are not permitted to administer them; those medications are administered solely by the hospice agency. In addition, the Department also asked (A#1) to describe the safeguards in place to prevent misuse of medications and ensure staff do not make statements implying misuse. (A#1) stated that medications are stored in a locked cabinet for safety, and staff follow physician orders and the “five rights” of medication administration. (A#1) stated that he has never heard any facility staff make statements threatening to overmedicate a resident in care.

On April 23, 2026, during interviews with witnesses (W#1) through (W#4), (4) out of (4) stated that they had not overheard staff discussing medications in a manner that seemed unusual or concerning. In addition, when asked whether they had conversations with staff about how medications are handled or administered to residents, (4) out of (4) stated that the staff take care of the residents’ medication needs and follow the prescribed orders.