Complaint Investigation Report

During the investigation, LPA interviewed (2) Administrators and (3) caregivers and a family member and reviewed documentation pertaining to medication administration for (3) current residents. Resident (R1) moved to the facility on 1/22/22 around the afternoon time and moved out on 1/24/22 early in the morning.

Allegation: Resident not administered medication as prescribed.

Allegation is resident (R1) is required to take melatonin once a day at 10:00pm but instead was being administered two melatonin at noon.

Interview with (2) Administrators indicated that resident (R1) refused medications starting on Sunday, 1/24/22 and would only accept from family members. One staff stated "(R1) re fused medications- she spit them out- we put them in applesauce and she still spit them out". A second staff stated he was not aware of any medication issues, and a third staff stated "I never gave her medications- I was off work".Administrator confirmed there is no documentation on file as resident's family requested that any documentation be shredded after resident moved out and the placement agency took some documents also.

LPA and staff (S1) reviewed medications for (3) residents (R2-R4) on 5/26/2022, including physician's orders, Centrally Stored Medication Record (LIC622) and Medication Administration Record (MAR) for May 2022. It was determined that resident (R2) had not received Docusate on 5/26/22, due to waiting for a refill, but had received it from 5/1/22- 5/25/22.

For resident (R3), Klor-Con-8-MEQ and Docusate 200mg were last administered on 5/25/22 in the morning, due to waiting on a refilled supply. Additionally, LPA observed an empty bottle of Atorvastatin-Calcium 40 mg, filled on 8/16/2021, and an opened bottle of Melatonin 10mg, to be stored with R3's current medications; Neither medication was listed on the May 2022 MAR and prescription orders, dated 8/25/2021 show that each medication is scheduled to be taken once daily.

For resident (R4), LPA and S1 counted 23 tablets of PRN Alprazolam 0.5 mg, filled on 5/15/22, and determined that 7 tablets were administered since 5/15/22; however, there is no documentation on file as required. New orders were written on 5/24/22 to discontinue Alprazolam and start PRN Haloperidol 2 mg. Administrator confirmed that the medication Alprazolam, was given but not documented.