Complaint Investigation Report

The investigation revealed the following: In regard to the allegation: Staff do not dispense medications in a timely manner. It was alleged that C1 miss their medication due to staff not dispensing them if C1 is not in their room.

Staff interviews revealed that medications are dispense as prescribed and are provided to C1 and other clients timely on a routine basis and are documented in the Medication Administration Record (MAR). Interviewed staff indicated that C1 often will go out in the community without informing staff and will return to request their medication. Also often C1 refuse to take the medications. (SIRs were provided to LPAs). Interviewed staff stated facility has a one-hour window on each side of hour C1 doctor has ordered to dispense C1 medication and it will be medication error if they will administrate prescribed medications to C1 the way how is C1 is requesting. Staff stated they encouraged C1 and other clients to take their medication, but staff will not administrate medication out of the window that client’s doctor has ordered. LPAs reviewed the MARs for the months of March, April and May 2025 and observed that C1 often missed their medications because was out of the facility or refused. LPAs reviewed documentation on the back of Medication Record which confirm what staff said and which days C1 refused or missed the medications. Interviewed C1 retracted their statement. C1 stated that they do not have any complaints about this matter. Interviewed C2-C5 indicated staff provide their medication as ordered by their doctor and is given on a timely and consisted manner. Interviewed Clients indicated they do not have any concerns about the staff administrating their medication and do not have any concerns regarding this matter.

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.

Exit interview was conducted and the copy of this report was provided to the Administrator Vida Andrade.