Complaint Investigation Report

It was alleged that Staff #1 (S1) provided the wrong medication to Client #1 (C1). To investigate this allegation, LPA conducted interviews with the Administrator, staff, and three (3) out of four (4) clients, and reviewed C1’s Centrally Stored Medication Record (CSMR) and related documentation. Interviews with staff and the Administrator revealed that all medications were administered in accordance with physician orders and the facility’s medication policies. LPA was informed that C1 frequently refused to take the prescribed Vitamin D3 (50 mcg) , and S1 documented each refusal appropriately. Interviews with clients indicated that on 02/23/2025 , C1 was transported to the hospital due to a general allergic reaction after taking Sumatriptan (25 mg) . It was initially believed that the medication had been administered in error. However, review of the CSMR and physician’s orders confirmed that Sumatriptan (25 mg) was indeed prescribed to C1 by the treating physician. The medication was subsequently discontinued on 02/23/2025 , following C1’s hospital discharge and physician’s direction.

Based on interviews and record review, there is insufficient evidence to conclude that S1 provided the wrong medication to C1. Although the incident occurred as described, the evidence obtained does not support that staff administered medication contrary to physician orders. Therefore, the allegation that S1 provided wrong medication to C1 is UNSUBSTANTIATED .

Exit interview conducted and copy of this report signed and delivered.