Complaint Investigation Report

LPA reviewed an email from 7/31/2023 from RP1 to facility management. It states over the weekend, RP1 received a call asking for Colchicine and Miralax for R1. RP1 asked when the medications were needed, and was told R1 was completely out and missed the morning dose. RP1 stated they never received a request to refill the medications prior to running out.

On 8/9/2023 at 12:35 pm, LPA conducted a medication audit of R1’s medications with administrator at the time present. LPA observed the following errors:

· Amlodipine Besylate 5.0mg started 7/18/2023; Med count: 21; should have been 22 count.

· Amlodipine 2.5mg started on 7/29/2023; Med count: 77; should have been 78. Administrator believes the med tech wrote down the wrong start date.

· Aspirin 81mg/day in AM; 500 tablets, started 9/19/2022; 324 days elapsed. Med count: 51; Short 125 tablets.

· Colchicine: 0.6 mg/1 tab/day AM: Started 7/31/2023; 90-day supply; 10 days from 7/31/2023 to 8/9/2023; Med count: 79; Should have 80; count is short one tablet.

· Ezetimibe: 10mg 1/day in AM; started 6/17/2023; 90 tablets; 54 days between 6/172023 & 8/9/2023; Med count is 36 tablets, 2 tablets short.

· 2 orders of Famotidine at 20mg/each order: Started 6/10/2023; 125 tablets to start; 1/day in AM, 1/day at bedtime; 61 days from 6/10/2023 to 8/9/2023; (61 x 2 = 122 tablets/day); Med count: 8 tablets; (On 8/9/2023, one tablet given in AM; bedtime tablet not yet given on 8/9/2023); Med count: 8 tablets; Over 4 tablets.

· Furosemide 40mg: Started 6/1/2023; 1 tab/day in AM; Bottle count: 90 at start; med count: 19 tablets; 1 tablet short.

· Hydralazine 25mg; Qty at start: 270; Start date: 5/31/2023; 1T/2x day at 9 am & 5 pm; 5/31/2023 – 8/9/2023 am: is 71 days; 5/31/2023 – 8/9/2023 pm is 70 days. Total of 141 disbursements; Med count: 130; Should be 129; One tablet over. Administrator stated he believed the start dates were incorrect.