Complaint Investigation Report

On the allegation, facility staff did not provide resident’s medication as prescribed. It was alleged that during Resident #1’s (R1’s) stay at the facility they were not provided with medications as prescribed by their primary care physician (PCP).

Record review revealed R1 moved into this facility on 9/19/2024. R1’s physician orders as of 9/22/2024 reveal R1 was prescribed the following medications: Alpha lipoic acid 600mg one tablet by mouth daily; brimonidine tartrate ophthalmic solution 0.2% one drop into affected eye two times daily; brimonidine tartrate-timolol ophthalmic solution 0.2-0.5% one drop ophthalmically into affected eye two times per day; gabapentin capsule 300mg one capsule orally three times per day; oxybutynin chloride 5mg one tablet orally two times per day; quetiapine fumarate 25mg one tablet by mouth in the morning and two tablets by mouth at bedtime; sertraline 25mg one tablet orally daily; tramadol 50mg one tablet by mouth twice daily; trazadone 50mg one half tablet by mouth at bedtime. The facilities Centrally Stored Medication and Destruction Records (CSMDRs) for R1 list all the medications above except for the alpha lipoic acid prescribed on 9/22/2024. The CSMDRs list gabapentin 300mg filled on 1/2024 with a quantity of 90 and started on 9/19/2024. Records show R1’s PCP sent orders for the alpha lipoic acid and gabapentin to the pharmacy on 10/11/2024, these are not listed on the CSMDR. The facility staff could not provide documentation showing the alpha lipoic acid was ever given as prescribed. The facility could not show documentation of the gabapentin filled on 10/11/2024 was given as prescribed after running out of the medication on hand started on 9/19/2024. R1 moved out of this facility on 11/10/2024 indicating R1 went approximately 22 days without gabapentin from 10/20/2024 to 11/10/2024. Interviews revealed when R1's PCP wrote a new medication order it was sent to JDX pharmacy, JDX pharmacy fills the order and delivers the medication to the facility. Licensee stated they do not know why they do not have documentation of these medications and realizes they should have ensured medications were given as prescribed.

Interview and record review reveal R1’s PCP changed their trazadone order to 100mg one tablet by mouth at bedtime on 10/11/2024 and their quetiapine fumarate to 200mg one tablet by mouth at bedtime on 10/08/2024. The facilities Centrally Stored Medication Record (CSMDR) for R1 does list these changes to R1’s medications. LPA verified the remaining medications listed on all CSMDRs received, and all records were found to be accurate.