Complaint Investigation Report

Allegation #2: Staff falsified a resident's records while the resident was in care.

Regarding the allegation, “ Staff falsified a resident's records while in care ,” The complaint alleged that staff are initialing medications they do not have or that have been discontinued.

During the department visit on 11/12/25, the department interviewed six residents, #1-6 (R1-R6), who denied the allegations. The department also interviewed three staff members, #1-3 (S1-S3). Two of the three staff members stated they mishandled R1’s medication while in care. The department reviewed the QuikMAR system and the medications for Resident #1 (R1). It was noted that two medications for R1 were marked as administered; however, one medication, Fluoxetine HCl 10 mg capsule, had been discontinued on July 7, 2024, but still appeared as administered in May 2025. Additionally, a new prescription for Fluoxetine HCl 40 mg capsule was issued on July 7, 2024, but it was also discontinued in May 2025.

The Department reviewed QuikMAR for Resident #1 and found the documentation for medication administration insufficient. Medications intended for oral administration as a single tablet every 12 hours were not accurately recorded. Med Tech did not initiate some entries; some medications were not documented when they were refused or when residents were out of the community; and others should not have been initiated for various reasons. Additionally, these medications should not be included on the list for administration by Med Tech for Resident #1 (R1).