Complaint Investigation Report

On 5/23/23 at 2:05 pm, LPA interviewed Donna Pieprzycki, RN/Nurse Consultant. RN states that she is not aware of any staff who have not given medications as directed, except one instance in September 2022. She says the staff got busy and made an error. She says the client’s physician was contacted and there were no adverse effects to the client. She says she has not seen or heard of any narcotics missing from the facility and states that clients who take narcotics would have extreme behaviors if not given these medications. She notes that these clients have not exhibited extreme behaviors.

On 6/6/23 at 12:39 pm, LPA interviewed Cindy Baker, Administrator. Administrator states that there are five (5) clients who take narcotics. She says if clients are screaming constantly, they are in pain, and staff would know if clients need their medications. She confirms staff had a medication error in September 2022, the client’s physician was contacted, and there were no issues with the client’s health due to the error.

On 6/6/23 between 1:05 pm and 1:25 pm, LPA interviewed staff. Staff say they have not witnessed nor heard of any staff making medication errors and have not found medications missing. Staff also say clients taking narcotics would have agitation and outbursts, if they missed their medications, and staff say they have not observed this.

On 6/6/23, LPA reviewed medications, Centrally Stored Medication List and MARS for Client #1 (C1). No issues were found.

Based on the evidence obtained, the allegation “Facility staff mismanaged resident's medication,” is deemed Unsubstantiated at this time.

Exit interview conducted, report given to the administrator.