Complaint Investigation Report

Based on a partial record review of 2 clients who passed away in May 2021--both of whom were receiving hospice care as well as podiatric care--there was no indication that facility LVN misreported wound status nor provided treatment without MD orders. However, sufficient information--including identities of clients--was not available.

It was observed that staff pre-pour clients' medications not more than 24 hours prior to administration to clients. However, it appears that not the same staff puts the pills in a designated disposable cup and gives the cup to the client, as meds are prepared by staff working a prior shift. According to facility's policies and procedures manual, "all staff will pour the medication each gives." A medication administration record is maintained to document which staff administered what medication to each client, and as per the facility's policies and procedures manual, "the MARs are initialed at the time the medication is placed in the cup." It cannot be determined if the staff who pre-poured the medications initialed the MAR, or the staff who gave the medication to the client.

Although these allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.