Complaint Investigation Report

Staff did not dispense medication according to doctor's orders.

On the allegation that staff do not dispense medication according to doctors’ orders, it is the concern of the Reporting Party (RP) that R1’s medicine patch was not removed and replaced as prescribed and was two days overdue. On 10/19/2023 and 05/22/202 LPA Venus Mixson conducted interviews, record review pertinent to the allegation and made observations related to the allegation. The interview with one hospice nurse revealed that their client was R1, and that R1did have a medication patch, which was part of R1’s pain management. Furthermore, the hospice nurse stated that it was the responsibility of the Hospice team and the facility staff to care for the replacement and documenting on the condition of the patch. The hospice nurse stated that at no time there were concerns regarding the dispensing of medication according to the doctor's orders or concerns brought to their attention by any residents or staff. On 02/26/2024, LPA Mixson interviewed R1’s responsible party, and the interview revealed that “they are pleased with the overall operation and the running of the facility. There have been some changes put into place to prevent what was a simple mishap”. Furthermore, the party responsible stated that all is well and there are no concerns, there are protocols in place from the Administration, and shared that R1 seems much happier. Interviews conducted with four (4) residents revealed that they have never missed any of their scheduled medications that are prescribed by their doctor. LPA Mixson made observations pertaining to the listed allegation: Medication Administration Records (MARS) charts were reviewed and there was no documentation alluding to "Staff did not dispense medication according to doctor's orders." Additionally, residents’ medication refusals were documented.

Although the allegation may have happened or is valid, based on the interviews, observation, record review, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation that Staff do not dispense medication according to doctor's orders is deemed Unsubstantiated at this time.