Complaint Investigation Report

LPA interviewed the facility coordinator who stated that it was discovered by staff #2 (S2) that the medication found in R1's room did not belong to R1 and this was communicated to R1's responsible party.

LPA interviewed R1 who was not able to recall the incident and stated he/she gets medications from staff twice a day- morning and night.

Based on facility's Program Description under Medication Support, it stated that medication will be centrally stored and monitored by designated and trained community staff unless arrangements have been made with the administrator and R1 and R1's responsible party did not have any arrangements with the administrator to keep his/her own medication in his/her room.

Based on R1's services and needs plan, R1 requires complete assistance with all medication administration by the facility. Therefore, there should not be any medication left unattended in R1's room.

Based on interviews, and record reviews, this allegation is substantiated as the facility did not ensure centrally stored medication was inaccessible to residents in care.

In regards to R1 was administered 2 shots of flu and COVID-19 vaccines on the same day as the 2nd doses were administered without a consent.

Based on the documents provided, the pervious Resident Service Director acknowledged that R1 was not supposed to receive another doses of the vaccine and the mistake was due to lack of facility staff present when R1 was being vaccinated. The previous Resident Service Director stated he/she and other staff were assisting the 3rd party Pharmacist with the vaccine clinic to make sure residents have their proper paperwork and consents for receiving the vaccines and toward the end of the day, the staff who was assisting the Pharmacist left to assist another unit as no one was waiting to be vaccinated. Subsequently, R1 went to the vaccine clinic and was vaccinated by the Pharmacist who did not check the consent.