Complaint Investigation Report

Administrator stated a new prescription of 100 mg was issued and was ordered to start on March 9, 2025. It was advised that Resident #1 died on March 9, 2025. Information obtained from interviews with additional staff advised Resident’s Physician’s Order for the 200mg was 14 days and then a new prescription was initiated. Staff indicated there were no concerns advised regarding the mismanagement of Resident #1’s medication. Information obtained from interviews with additional staff indicated there was no information provided regarding R1’s medications being mismanaged. Information obtained from interviews with Hospice Nurses advised the medications were provided to the facility labeled and in bubble packs. It was confirmed Resident was prescribed 200 mg. Additional information obtained indicated when Hospice Nurses are not available, facility staff will distribute medication. Interviews with additional residents did not indicate any issues or concerns regarding medication management. A review of Resident #1’s Physician Order dated February 11, 2025 indicated Resident was prescribed 200 mg of the medication for 14 days and then a prescription of 100 mg was initiated. Medication Administration Record dated from March 1 to March 31, 2025 indicated Resident was prescribed 200 mg of the medication until March 8, 2025. No additional documentation is recorded due to Resident’s death. The last dosage of 200 mg was given on March 8, 2025. A review of additional records revealed there were no documentation of errors or missed medications. Due to the passing of Resident, LPA was unable to obtain additional information regarding the distribution of medication. LPA also attempted to interview additional witnesses regarding the allegations, but was unsuccessful in their attempts.

Regarding the allegation that staff restrained resident in care. Additionally, it was reported resident was slouched in the bed with their head against bed. Information obtained from interview with Administrator denied this allegation. Administrator stated Resident #1 does require total assistance for transferring from chair to bed.