Complaint Investigation Report

RP states that carbidopa levodopa was often not on time as directed by doctor. Interviews with two witnesses state R1 had expressed concern that the Parkinson’s medication carbidopa levodopa was not given as ordered. Interview with witnesses, F1, and administrators all state medication orders for Parkinson’s would change “all the time.” LPA reviewed Centrally Stored Medication and Destruction Record (CSMDR) and Medication Administration Records (MAR), these records along with Physician Visits notes showed orders for Carbidopa changed at least 4 times since November of 2024.

A CSMDR medication note is written in that an order for 2 tabs by mouth 6 times a day started on 10/21/24 by Physician #1. 11/2/24 2 tablets 3 times a day by Physician #1. 12/3/24 2 tabs by mouth 6 times a day by Physician #1.

Physician Visit notes by Physician #2 on 3/21/25 stated to “remove the extra 2 carbidopa…” then lists 5 different times to distribute. Then another change by Physician #2 of this medication on 4/21/25 back to 6 times a day. LPA reviewed the CSMDR and found that the 2 orders noted on the Physician Visit notes were not updated on the CSMDR records and the MAR due to Physician #2 is not the prescribing physician and the prescribing physician #1 would be upset with the attempt to override their orders.

Additionally, the CSMDR has a record that a prescription from Physician #1 with the same prescription number as the October through March orders was started on 4/5/25 and is the only Carbidopa medication listed on the CSMDR which kept the order of 2 tabs by mouth 6 times a day.

Physician Visit documented on 5/8/25, notes from Physician #3 state R1 was swollen and there was to be an increase in Furosemide. Physician visit note shows Physician #4 on 5/16/25 noted “lasix 40 mg daily”. Furosemide and Lasix are the same medication. The new medication was not filled until 5/16/25 and was not started per the CSMDR until 5/21/25. Per documentation, this is a delay in following doctor’s order for at minimum 12 days and 5 days following receipt of the medication. Continued on 9099C