Complaint Investigation Report

9099C-1... ** T his page was amended on 10/4/23 to include additional information from the MAR that was provided to the Department during the investigation and to note that a separate citation will be issued on a 809 report, dated 10/4/23, for the following substantiated allegation. A new signature was also obtained **

Allegation: Staff mismanaged resident’s medication. Complaint alleges that (3) bottles of Galantamine (30 pills each) were filled and dropped off 3/17/23 at the facility. On 4/22/23, (R1's) family member was notified by staff that this medication was out and needed to be refilled. (R1's) family member confirmed with the pharmacy that the medication was last filled on 3/17/23 for a quantity of 90 pills and was told that the facility would determine where the missing pills were.

(R1's) family members stated the Administrator during this time stated she was not aware of the situation and could not provide a resolution, and the facility “guessed” that the medication accidentally was assigned to another patient when (R1) was moved to that patients room and the medication was accidentally destroyed because the other patient was no longer at the facility. RCC stated on 5/12/23 that before the prior Administrator left the community, (S1) Med-Tech, called the family and said the facility was missing a bottle of medication for her Dementia. RCC confirmed the missing medication was Galantamine and (S1) claimed the bottle was missing, and the February bottle was at home for a while since it was a 90-day supply. RCC explained that (R1's) health care provider said the February bottle/medication was delivered to the family member's house. Both family members who were interviewed confirmed that (R1) never received the medication (3 bottles) with one member stating “she (R1) never got any of the 90-day medications, asserting they "disappeared"., and stated her father, had some supply of the same medication, same dosage, at his residence at another location.

MAR for February 2023 and March 2023 appear to have staff initials in each box, as for other medications given on the same day and time (am); however, entries on 3/4 through 3/17 appear to also have a circle around them for the medication, Galantamine. There are no entries on the April 2023 MAR for Galantamine from 4/1- 4/7 or on 4/15 and 4/16, and for (2) other scheduled medications on these same days; there is an entry on 4/1 and 4/2 only for the medication, Tamsulosin, that it was administered in the morning. The MAR for May 2023 has entries on all days for Galantamine, except for on 5/13 and 5/14, which was also observed for medications, Losartan and Lovastatin.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. NOTE: A separate citation was not initially issued on 9/29/23 but is being issued on a separate report, dated 10/4/23 . cont on 9099C2...