Complaint Investigation Report

The allegation of “Staff is mismanaging resident's medication.” Alleges that the facility is not giving resident #1’s (R1) medication as prescribed by their physician. LPA reviewed R1’s medications and observed R1’s prescription bottle of Medication #1 (M1). LPA observed M1 to be filled on 08/31/2025 with the administration instructions of “Take one (1) tablet by mouth two (2) times a day as needed for…” LPA observed M1’s dispensed quantity to be sixty (60) pills. LPA observed the M1 bottle to contain three (3) remaining pills. LPA reviewed R1’s Centrally Stored Medication and Destruction Record Sheet (CSMDR) and did not observe M1 to be logged accurately on the CSMDR. This deficiency is addressed in a separate Case Management-Deficiencies report. All of R1’s other medications were logged appropriately on the CSMDR. LPA interviewed the Administrator who stated that R1 consistently asks the facility for more M1 but stated that the facility is following the doctors’ orders on dispensing the medication to R1. LPA was unable to determine the exact start date of the medication due to the incomplete CSMDR but LPA informed the Administrator that there are a minimum of seven (7) M1 pills missing from the bottle. The Administrator confirmed that they are the only staff member trained to handle resident medications. The Administrator denied administering extra medication to R1 despite R1’s requests. The Administrator informed LPA that Staff #1 (S1) witnessed Staff #2 (S2) administering extra an extra M1 pill to R1 on two (2) separate occasions. LPA interviewed S1 with the assistance of telephonic interpretation services and S1 corroborated this statement. S1 informed LPA that S2 had given R1 extra M1 pills on two separate occasions but did not recall the dates this happened. S1 also confirmed that they had given R1 an extra M1 pill on one (1) occasion earlier this morning (09/24/2025). S1’s file was observed, the Administrator was unable to provide LPA with S2’s file. This deficiency is addressed in a separate Case Management-Deficiencies report. LPA observed that S1 did not have the required trainings to handle resident medications. This deficiency is addressed in a separate Case Management-Deficiencies report. LPA informed the Administrator that the three (3) instances of S1 and S2 administering an extra pill still do not explain the discrepancy in the medication count. The Administrator again denied giving R1 extra medication but could not account for the extra missing medication. Two (2) residents interviewed denied missing medications or being given extra medications by facility staff. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff is mismanaging resident's medication.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.