Complaint Investigation Report

LPA reviewed Medication Administration Record (MAR) from August 2022 which revealed M1 was last given and discontinued on 8/4/2022. A discontinue order for M1 was dated 8/4/2022 from R1’s physician. LPA conducted interviews with (5) staff who cared and administered medications to R1. (5) of the (5) staff interviewed revealed they could not recall if R1 was given medication past the discontinued date. Therefore, M1 was discontinued according to the physician’s orders.

It was also alleged Medication #2 (M2) was not given to R1 for (4) days in August of 2022, as the medication was not refilled in time.

MAR for August 2022 revealed M2 was administered and initial by staff every day. However, the Alert Charting Notes documented on 09/04/2022 revealed R1 had ran out of M2, on 09/07/2022 staff called R1’s pharmacy to order an emergency supply of M2, and on 09/08/2022 M2 was still not received by the facility. LPA reviewed the facility’s program plan on medication refills. Page 86 revealed staff would contact the dispensing pharmacy to obtain a refill at least (7) days prior to running out of a medication.

LPA conducted interviews with (5) staff who cared for and administered medications to R1. (5) of the (5) staff interviewed revealed they could not recall if R1 ever ran out of medications. Staff revealed it is the facility’s procedure to contact the resident’s pharmacy ahead of time before medications run out. Therefore, the facility did not contact R1’s pharmacy in time to refill their medication.

It was further alleged that R1 was being administered medications in incorrect intervals as Medication #3 (M3) was ordered to be taken 12 hours apart and was being given (8) hours apart. LPA reviewed the MAR sheet for R1 which revealed M3 was prescribed twice daily every 12 hours. MAR for August 2022 and September 2022 revealed M3 was being given (9) hours apart with initials at 8am and at 5pm.