Complaint Investigation Report

Staff interviews informed that staff discovered one of R1's prescriptions to be missing, and upon investigation it was found that R1 had taken the prescription to their room, having refused to give them to staff. Staff interviews further revealed that staff took timely action upon the medication discovery, and were also in regular contact with R1's Case Manager about R1's behaviors and missing medication. R1 was not able to be interviewed due to being away from the facility during the facility visit. Interview with R1's Case Manager corroborated staff statements that the Case Manager was informed of the missing medication, medication refusals, and behavior changes.

Records review corroborated staff statements regarding R1's medication refusals. R1's Medication Administration Record showed medication refusals from 7/1/24 to 7/9/24 for all medications except one. Records also revealed staff documentation regarding R1's refusals, increased behaviors, and staff's communication with R1's Case Manager. R1's Physician's Report showed that R1 could leave the facility unassisted and that R1 required medication management assistance.

During an unannounced facility visit, LPA directly observed the location of the centrally stored medications for residents. The medications were organized by resident name and stored properly, including refrigerated medications. LPA observed the medications to be in locked areas with access via keys that only staff held. LPA did not observe any medication in R1's room during the facility visit.

The investigation revealed that while the medication in question did come to be stored outside of the central location, facility staff took action right away to rectify the situation and notified the appropriate persons. The investigation revealed a conflict within the VA system for how medications were delivered to residents who were not supposed to have access to them. Consultation was done with the Licensee and R1's Case Manager to adjust the process for how medications are accepted at the facility, to include additional measures to prevent resident unsupervised access to prescriptions.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Bessie Pascual, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.