Complaint Investigation Report

Interview with Staff 1 (S1) confirmed that the resident was receiving appropriate care and supervision in accordance with their care plan. Staff responded immediately when the resident was found unresponsive and contacted emergency services. Interview with Staff 2 (S2) described the events leading up to the incident and confirmed that the resident had not expressed any new complaints or symptoms prior to the event. Interview with Staff 3 (S3) verified that all medications were administered as prescribed and that the resident’s condition was stable during the days leading up to the incident. Interview with Outside source 1 (OS1) stated they were satisfied with the care provided and had no concerns about staff attentiveness or neglect. Confirmed that the resident’s death was consistent with their known medical conditions and not indicative of neglect.

LPA observed the facility appeared clean, organized, and appropriately staffed at the time of the visit. Staff were observed following care protocols and referencing resident care plans during shift transitions.

On 07/05/2023, the department received a complaint alleging that medication was not given as prescribed.

LPA reviewed R2’s physician orders dated included prescriptions for R2's medical needs. The Medication Administration Records (MARs) for the past 30 days showed consistent documentation of medication administration with no missed doses or discrepancies. Centrally stored medication logs were complete and matched the medications on hand.

Interview with S1 confirmed that all staff responsible for medication administration are trained and certified. Stated that MARs are reviewed weekly for accuracy. Interview with S2 demonstrated knowledge of Resident 1’s medication regimen and described the facility’s double-check system for medication passes. Interview with S3 reported no issues with medication refusals or errors for R2.

Outside Source 1 (OS1) stated they receive their medications daily and have not experienced any missed doses. Responsible Party: Reported no concerns regarding medication administration and confirmed that the resident’s health has been stable.

LPA observed medications were observed to be properly labeled, stored in a locked cabinet, and organized by resident. Staff were observed following proper procedures during a medication pass, including verifying the resident, medication, dosage, and time.