Complaint Investigation Report

Review of medication records and interviews revealed that R1 received multiple medications a day and received medication management services by the facility. Review of R1’s medication administration records noted multiple instances in early May 2023 where R1 requested to take the medication at a different time than prescribed. Medication records did not reveal any instances where medications were missed or not given to R1. Interviews with staff revealed that R1 had requested that medications were given to them at a specific time and would get upset with staff if they were unable to meet that specific time period. Interviews with staff revealed that staff were able to give a medication to a resident within an hour prior to and an hour after the time a medication was ordered to be given. After that 2 hour window, the medication would be considered missed. Staff interviews revealed that if a resident refused a medication, staff would attempt to give the medication to the resident a total of 3 times before marking the medication as refused. Staff would also change the staff member giving the medication to the resident in an attempt to have the resident accept the medication from a different individual. Staff interviews revealed that staff would attempt to understand why a resident was refusing a medication and would work with the resident to decrease the likelihood of medication refusal. Interviews with staff and residents did not reveal any issues with staff assisting residents with medication administration.

Interviews with staff and R1 revealed that R1 was difficult to work with, became angry often, and had a history of yelling at staff. Interviews revealed that R1 would get upset when medications were given differently than how R1 expected medications to be given. Interviews revealed that R1 would curse and yell at staff and staff began passing medications to R1 with another staff present. Facility management also reviewed the prescribing orders with R1 and changed the staff responsible for passing medications to R1 in an effort to decrease R1’s agitation. Interviews with staff revealed that facility management was in contact with R1’s responsible party to address R1’s agitation and the responsible party was able to explain the medication orders to R1.