Complaint Investigation Report

On 12/12/2022, the Department received a complaint in which it was alleged that the staff are not assisting with self-administration of medications. During the medication audit the following was noted:

- Client #1 (C1): The current start date per the centrally stored medication and destruction record for Vitamin D3 was 12/01/2022., There was six (6) pills left in the bubble pack; if it were properly distributed, C1 would have nine (9) pills remaining in the bubble pack.

- Client #2 (C2): The current start date per the centrally stored medication and destruction record for Fluconazole was 11/30/2022. There was four (4) pills left in the bubble packet; if it were properly distributed, C2 would have three (3) pills remaining in the bubble pack. Per physician’s order, Fluconazole is to be taken 1 tablet by mouth every three (3) days, however for 12/11/2022 the pill is still in the bubble indicating that staff did not properly assist C2 with the self-administration of the above medication. Interviews with staff revealed that C2 went home during the time of the medication error.

- Client (C3) #3 , the current start date per the centrally stored medication and destruction record for Oxybutynin was 11/30/2022. There was six (6) pills left in the bubble pack; if it were properly distributed, C3 would have eight (8) pills remaining in the bubble pack.

- Client (C3) #3 , the current start date per the centrally stored medication and destruction record for the Metamucil 30 pack was 10/23/2022. As of today, there 11 packs remaining. Whereas staff claimed that C3 was assisted with the self-administration of this medication daily, staff were unable to clarify the discrepancy, as all of these packs should have been dispensed to the client and a new medication packet should have begun. -

Per medication audit and interviews throughout the investigation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.