Complaint Investigation Report

This report supersedes the reports created on 4/16/25, the findings remain the same.

Allegation: Staff are not distributing a resident's medication as prescribed.

The Department conducted an interview with Administrator Rony Shram, who stated he conducted an internal investigation, in January 2025, after learning that R1 experienced a Medication Administration error while residing in the facility from July 2024 to February 2025. Administrator Shram reported R1 received (1) tablet of Namenda 10 mg per day after an E-MAR system change occurred in July 2024. R1's physicians order reflected (1) tablet of Namenda 10 mg (2) times per day and the second tablet was not administered after the system change as the new E-MAR did not reflect the order for the second tablet. Administrator Shram self-reported the error and submitted an Unusual Incident Report (UIR) to CCL on January 29, 2025. The Department conducted interviews with LVN Wendy Cuadle (S1), who confirmed R1 received (1) tablet of Namenda 10 mg one time per day after the E-MAR system change occurred in July 2024. The Department interviewed Residents R2-R4 and found 3 of 3 Residents expressed no issues with staff assistance with Medication Administration. The Department interviewed Staff/Med Techs (S2-S3). S2-S3 stated Medication Administration training is provided prior to Med Techs administering medication independently. The Med Techs interviewed stated they administer and record passing medication on the E-MAR. The Med Techs interviewed stated they follow protocols per their training. The Department obtained and reviewed R1 physician's order (Dated:5/17/24) and R1's Medication Administration Records (Dated August 2024-Febuary 2025). The Department confirmed R1 received only (1) tablets of Namenda (Generic name: Memantine) 10 mg per day starting in August 2024 - February 2025.