Complaint Investigation Report

Resident interviews revealed that when R1 was asked about insulin injections, they confirmed they have neither administered their own insulin at the facility, nor have they had any staff members administer it for them. R1 stated they've received their insulin injections from outside medication management agency. R1 was able to corroborate staff interviews.

Outside Source interviews revealed that Outside Source 1 (OS1) was not aware of R1 injecting themselves with insulin as part of their routine in the facility. OS1 confirmed R1's memory is not reliable. OS1 stated that in regards to the reporting party's incident report, it is very possible R1 could have misremembered the events when retelling the reporting party.

Records Review revealed that R1 takes oral medication to manage their diabetes. The medical administration record (MAR) has no indication of injectable insulin medications. The Physician's report indicated that while there is no direct mention of a diagnosed cognitive disorder, it is stated that there is "forgetfulness" and "other specified mental disorders due to known physiological condition" which corroborated outside source accounts of R1's memory impairment.

LPA observations revealed that inspection of the medications at the facility, R1 had no injectable insulin medications. All medications were prepackaged and provided by outside medication management agency and LPA was able to corroborate staff accounts of medication management.

Based on records and interviews, the allegation that Staff gave resident medication without a physician's order is unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. The allegation has therefore been dismissed. An exit interview was conducted with the Caregiver Paola Castillo, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.