Complaint Investigation Report

S1 stated that their are various reasons a medication would not be dispensed to a resident, but regardless of the reason it is always logged in the MARs. S1 stated that when they dispense medication to a resident, everything has to be "grayed" out on the computer system, meaning the medication was logged and charted and they can move on to the next resident for "med-pass."

LPA interviewed Staff 2 (S2) who stated that they have worked at the facility for over four years. S2 stated that they work both in the memory care unit and assisted living. S2 stated that whenever a resident is not given their medication the reason is logged in the "system." S2 stated that their would never be a time when a staff member would not log in a medication that was not dispensed. S2 stated that S2 meets every week with unit directors to discuss the "exceptions" or the medications that were not dispensed and "trends." S2 stated that the facility recently changed pharmacies which caused a delay on receiving various medications for residents. S2 stated that R1 has not had any medication errors or missed medication. S2 stated that S2 personally investigates and writes incident reports anytime their is a medication error. S2 stated that they review and discuss the medication error with the unit directors and notify the Executive Director.

LPA interviewed Staff 3 (S3) who stated that they have worked at the facility for over 10 years. S3 stated that they dispense medication in both the assisted living unit and the memory care unit. S3 stated that whenever a resident is not given their medication the reason is logged into the computer system. S3 stated that their would never be a time when a staff member would not log in a medication that was not given and the reason. S3 stated that they are familiar with R1. S3 stated that they recall giving R1 their PRN of Tylenol frequently for pain. S3 stated that their were no medication errors or missed medications for R1.

LPA interviewed Assisted Living Director (ALD) who stated that R1 was on eight routine medications and four PRN medications during their stay at the facility. ALD stated that prior to a resident going out in the community it is facility protocol to sign out their medications with the person who is taking the resident. If a resident leaves via emergency services a medication list is printed and given along with medication instructions. ALD stated that staff order medications through their house pharmacy or the through the residents’ responsible party. If a resident chooses not to use the house pharmacy, the responsible party will order and deliver medications to the community upon request. If a resident uses the house pharmacy and they do not have medications on hand, it could be due to needing a new signed order from the Primary Care Physician (PCP) or a delay in delivery from the pharmacy. Facility staff along with the house pharmacy would continue to contact the PCP until the medication order is signed and sent to pharmacy.