Complaint Investigation Report

Regarding, “Staff over medicated resident in care resulting in hospitalization.” It was alleged that the resident was transferred to the hospital and was diagnosed with being over medicated on Medication #1 (M1). A records review was conducted by the department where it was found that Resident #1 (R1) had been prescribed M1 (3) tablets at night. LPA reviewed the MARS log for R1 and found that the medication had been accounted for. LPA reviewed the hospital discharge paperwork where it was found that on 8/20/2020 the resident was admitted for altered mental state and diagnosis of intoxication due to M1. LPA interviewed the administrator who stated they were unaware of how the resident had overdosed on M1. It was unable to be corroborated if the staff had administer a higher dose to R1. Therefore the allegation that R1 had been given too much medication by staff was found to be unsubstantiated.

Regarding, “Staff are not ensuring resident's needs are met.”, it was alleged that the facility staff refused to assist R1 with their blood pressure cuff, and had not dialed 911 when the resident requested staff to do so. LPA spoke with administrator who stated they could not recall calling 911 on the day of the incident but stated they do not refuse medical attention to their residents. Therefore, the allegation is unsubstantiated.

Findings that are unsubstantiated mean that although the allegation may be valid, the preponderance of the evidence standard has not been met. An exit interview was conducted with Administrator, Vicki Estelle where this report was reviewed and provided to them.