Complaint Investigation Report

Allegation: Staff mismanaged resident's medication

The details of the complaint alleged that facility staff are mismanaging clients in care medications.

During the records review, LPA Iniguez examined the Medication Administration Records (MARs) for clients C#1 through C#6 from January to May 2024 and found consistent documentation. Additionally, LPA observed the annual staff training "Policies and Procedures Regarding Medications" dated 12/1/23.

During a physical review of the client’s medications, LPA observed that all the client’s medications were stored in a centrally locked area accessible only to the facility staff. LPA Iniguez examined the client’s physical medications, which were packaged in a bubble pack with the pharmacy's name, prescription number, client's name, medication name, dosage, physician's name, directions for taking medication, number of refills, and expiration date. LPA did not observe any medications without clients’ names, dosages, or other essential indicators.

During an Interview with the facility administrator (A#1), she mentioned that the facility staff administers medications to clients in the morning and at night. The staff receives medication training from the pharmacist once a year. Additionally, (A#1) clarified that case managers from Telecare do not dispense prescribed medications to facility clients, she stated they are not allowed to go near where the clients’ medications are stored; only the facility staff does. Furthermore, (A#1) assured that all clients in care receive their medications as prescribed by their physician.