Complaint Investigation Report

Details of which medications were missed were not provided or obtained during the investigation.

Based on interviews and Medication Administration Records (MARs) review, there was insufficient evidence to support the allegation. Review of the MARs from August 1, 2021 to October 8, 2021 for C1 and C2 was documented and initialed as being administered as prescribed. Specifically, on September 19, 2021 all medication entries on the MARs showed no medication errors documented for C1 and C2. Staff and outside sources consistently denied knowing of any medication administration errors for C1 or C2. Specifically, S1 denied the allegation. LPA was able to determine during the course of the investigation that staff received required annual training on medication administration including S1. Interviews with staff consistently confirmed all staff including S1 were knowledgeable of the correct protocols to follow when medication errors occurred. No exceptions to these protocols were disclosed or discovered during the investigation. No third-party concerns regarding medications were received during the time frame of September - October 2021 and there was no indication of any adverse outcomes to clients.

Based upon a lack of evidence that facility staff did not administer medications as prescribed, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted, and a copy of this report was provided to Administrator, Davalos at the conclusion of the visit. Davalos was provided a copy of Licensee Appeal Rights (LIC 9058), and her signature on this report acknowledges receipt of copies of the rights and the report.