Complaint Investigation Report

The investigation revealed the following in regards to the allegation: “Staff mismanaged resident medication.” It is alleged that on 12/26/2024, client medications and the Medication Administration Records (MAR) were reviewed and checked against the physician’s prescriptions. The following issue was identified during that review: On 12/25/2024 Medication Metropol 25mg and Lithium Carb 300 mg was not dispensed for C1. The medication error was not identified by the DSP or Administrator prior to the evaluation nor was the incident documented in the MAR or Client Notes. 3 out of 3 staff interviewed cannot recall nor confirm of staff mismanaging resident medication. 3 out of 4 clients denied the allegation. 1 out of 4 clients stated that the staff mismanage medications by providing them at a same date but different time. Based on interview, Administrator stated at that time medication is dispensed through bubble packs at the home but the hospital provided 30-day supply of pill bottles for C1 which caused confusion for the staff that dispense medications. Administrator stated that all required medications were administered. In addition, SGPRC conducted an investigation regarding this allegation which was substantiated. As a result of this, the Administrator re-trained medication management S1 for 2/6/2025 and S2 for 2/20/2025 and placed both S1 and S2 on a 60-day administrative oversite. Based on observations, record review, and interviews conducted with facility staff, and facility residents, there was sufficient supportive evidence to concur with the reported allegation.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

An exit interview was conducted with the Administrator, Melissa Vazquez. A copy of the report and appeal rights were provided.