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. 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 clients have not exhibited extreme behaviors.

On 6/6/23 at 3:30 pm, LPA interviewed Cindy Baker, Administrator. Administrator states there are three clients who take narcotics. She says there have been no medication errors in the facility and no staff have ever been counseled for medication errors.

On 6/6/23 between 3:45 pm and 4:03 pm, LPA interviewed staff. Staff say they have not observed clients not receiving their medication as prescribed. They express they have never seen staff taking clients’ medications from the facility. Staff say one client “mellows” after taking their medications. Staff say they understand clients’ thoughts and feelings by viewing their facial expressions, noises, and body language and that they ask clients how they’re feeling after medications are given. Nurses say medication audits are done at the end and start of every shift with two nurses present during the audit, and they have not found any issues with medications being given.

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

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.