Complaint Investigation Report

A review of R1's documents was conducted. On 03/18/2026, the facility received a physician order for R1's Quetiapine. This order stated "25MG, take 1/2 tablet (12.5MG) by mouth daily at bedtime as needed for agitation." Review of R1's medication authorization record (MAR) showed that facility staff entered this order manually on paper and administered the Quetiapine from 03/18/2026 to 03/22/2026.

On 03/23/2026, the facility received a new order for R1 which stated, "Quetiapine, 25MG, take 1/2 tablet (12.5MG) daily at bedtime." Review of R1's MAR showed that facility staff entered the new order manually on paper and administered Quetiapine from 03/23/2026 to 03/31/2026.

Review of R1's medication list for 04/09/2026 stated R1's Quetiapine order as, "25MG take one-half tablet (12.5MG) by mouth at bedtime for insomnia, dementia related agitation." Review of R1's MAR for April 2026 showed that R1's Quetiapine order was manually entered on paper as "Quetiapine, 25MG take half tablet by mouth at bedtime." It was observed that facility administered Quetiapine for April 2026 appropriately per the paper MAR.

Facility received an updated medication list for R1 on 05/07/2026. This list also stated that "25MG take one-half tablet (12.5MG) by mouth at bedtime for insomnia, dementia related agitation." Review of R1's MAR for May 2026 showed that R1's Quetiapine order was manually entered on paper as "Quetiapine, 25MG take half tablet by mouth." It was observed that R1 was administered Quetiapine for May 2026 appropriately per the paper MAR.

Interview conducted with Health Services Director stated that after sending the new orders to the pharmacy, the pharmacy didn't input or profile R1's Quetiapine orders correctly into the electronic MAR. As a result, facility staff started a paper MAR to document when the Quetiapine was being given to R1.

Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated . A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.