Complaint Investigation Report

The investigation revealed the following:

Regarding: Staff is mismanaging residents' medications.

It is alleged that staff documented in the system that bedtime medication was given to resident; however, resident was not at the facility to receive their bedtime medication due to being on an outing. It is also alleged that resident’s bubble packs were observed with the bedtime medication popped and that staff did not know where the medication went or if it was thrown away.

Interview with S1 revealed that S1 received a report from S3 that R1 did not receive their bedtime medication after returning from a trip outside of the facility on 3/24/2026. S3 who came on shift after S2 ended their day, informed S1 that when R1 and their responsible party returned from an outing on 3/24/2026 at about 11:30 p.m., they approached the med-tech room to have staff provide R1 with their bedtime medication. S3 indicated that the bedtime medication appeared to have been already popped and given to R1 by S2 when cross check was conducted on the Medication Administration Record (MAR) by S3. S1 indicated that S3 informed S1 that when checking the MAR, it was noted that R1 had already been given their medication by S2, even though R1 was not at the facility during the bedtime medication pass was conducted. S1 indicated that they spoke to S2 on 3/25/2026 and was informed that S2 acknowledged “popping” R1’s bedtime medication and documenting on MAR ahead of time thinking that R1 was at the facility. S2 informed S1 that R1’s medication was placed in a medication cup but was unable to recall where the medication went. S1 stated that removing medication from bubble packs ahead of time is not appropriate practice for medication management and conducted on the spot training with S2 during audit of R1’s medication. LPA attempted to interview S2 and S3; however, they did not return LPA's calls. LPA conducted random review of medication and found, R2 has discontinued Rx-Furosemide 40 mg no longer administered but still listed on MAR. Based on interviews, observations and record reviews the allegation that staff mismanaged resident’s medication is corroborated.