Complaint Investigation Report

It was further revealed through interviews that although the physician’s order was in place, C1 did not receive medication and displayed signs and symptoms requiring use of the medication on at least three different occasions. Interviews also revealed that C1’s responsible party inquired about availability and use of the inhaler during the early part of November 2024, and learned from staff that medication was not available. Additionally, it was revealed through interviews and record reviews that C2 has a physician’s order for use of EpiPen with medication, however, such device was not available in medication storage at facility for use as necessary. Interviews and record reviews conducted revealed that medication orders existed, and clients noted above were previously assisted with medication, however, were not assisted recently due to medication misplaced. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Medication lost. LPA conducted interview and record reviews as noted above. Based on interviews and record reviews it was determined that client1 (C1) has a physician’s order which states “Albuterol inhaler every 4-6 hours for shortness of breath (SOB) wheezing as needed.” Additionally, it was determined that C2 has an order in place for use of an EpiPen with medication as needed. Interviews conducted revealed medications noted above had previously been in storage and dispensed to clients with assistance while at facility’s previous location prior to facility’s move to their current location on 7/31/2024. Interviews further revealed that when C1’s responsible party inquired about the use of C1’s inhaler, it was expressed that inhaler could not be found, and revealed staff was not aware of an order for the inhaler. Sufficient evidence could not be found to indicate medication accountability for C1 and C2 after facility’s location move, and interviews conducted indicated medication was lost during this transition. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Facility did not meet its reporting requirements . LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that physician orders for medication existed for C1 and C2, however, not dispensed due to medication misplaced. Interviews further revealed that facility staff, upon learning of the misplaced medication and clients not received medication due to the misplacement, did not report incident to licensing department per regulatory requirements. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

As a result of this investigation, citations are issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Program Director and a copy of this report was provided. LIC 811 and Appeal Rights provided. PD gave permission for S1 to sign this report in her physical absence.