Complaint Investigation Report

Allegation: Staff did not dispense resident’s medication(s) as prescribed- Substantiated

On 03/28/24 LPA Ratajczak and LPA Mirlohi conducted a medication audit of five (5) residents’ medications. Medication orders were compared to medications being administered and documentation on the Centrally Stored Medication List (LIC622) and Medication Administration Record (MAR) was reviewed. The following discrepancies were noted for three (3) residents, as follows:

Resident #1 (R1)- LPA compared the current medication orders from facility MAR to the medications stored at the facility. LPA observed medication Fluoxetine HCI Oral Capsule 40 mg available to resident however the MAR showed resident missed medications on March 1, 2024 through March 5, 2024. MAR states, “Pharmacy action required” and “other/see nurse notes”. Administrator stated there were no notes documented. LPA observed medication Locaine external patch 4% was available to resident however the MAR showed resident missed medication on March 1, 2024 through March 5, 2024. MAR states, “Pharmacy action required” and “other/see nurse notes”. Administrator stated there were no notes documented. LPA observed medication Lisinopril Oral Tablet 40 mg was available to resident however on the MAR it shows resident missed medication on March 1, 2024 through March 5, 2024. MAR states, “Pharmacy action required” and “other/see nurse notes”. Administrator stated there were no notes documented. LPA observed medication Seroquel tablet 25 mg was available to resident however LPA observed the MAR showed resident received 12 medications however there were only 11 pills popped from the bubble pack. LPA observed medication Montelukast Sodium 10 mg, and observed the bubble pack was started on March 13, 2024. LPA observed there were 4 missing pills from the bubble pack. LPA observed resident PRN medication Hydrocodone-Acetaminophen tablet 5-325 mg was not available to resident. Med Tech stated they will reorder medication today.