Complaint Investigation Report

R2 received Atorvastatin 20 mg, however, the physician's order prescribed Atorvastatin 10 mg, one tablet by mouth at bedtime. On 05/01/2024 at approximately 9:00 p.m., Resident 3 (R3) was administered another resident's bedtime medications, including Ativan and Norco.

LPA Lee also reviewed Medication Administration Records (MARs) for seven residents for May 2024 and identified two documentation discrepancies. Resident 4 (R4) was prescribed Ocean Blue Omega-3 2100 mg, one capsule by mouth daily, with a start date of 05/02/2024 and an end date of 10/10/2024. The MAR did not have staff initials from 05/02/2024 through 05/06/2024, and no documentation to explain the omission. Resident 5 (R5) was prescribed Methylphenidate 5 mg tablets, two tablets (10 mg) by mouth three times daily, with a start date of 02/29/2024 and an end date of 08/21/2024. The MAR contained no staff initials for the morning, noon, or evening medication passes on 05/02/2024 and from 05/06/2024 through 05/16/2024. No notes were documented explaining the missing entries.

Based on facility incident reports and the review of resident MARs, the investigation revealed medication administration errors, as a result, the allegation is found to be SUBSTANTIATED, meaning the allegation was found to be valid because the preponderance of evidence standard was met.

The following deficiency was not cited as the same citation was already cited on complaint control number 22-AS-20240919164250. An exit interview was conducted with FDA Turner. A copy of this report was provided to the facility via email, and a certified copy will be mailed to the facility's address of record.