Complaint Investigation Report

It was also alleged that staff did not follow R1’s care plan as R1’s care plan states he/she is not on medication management when staff removed the medications from R1’s bedroom.

1 staff member was interviewed regarding this investigation. This staff member was present and involved in removing R1’s medication from R1’s bedroom. Based on staff interview, R1 was not under medication management during the time of move-in and the General Manager at the time approved R1’s spouse to help administer R1’s medications. One day [specific date unknown], S1 was directed by the General Manager to remove R1’s medications from his/her room. The reason the medications needed to be removed was after the facility nurse determined R1 needed assistance with medication management after completing a 30-day medication evaluation after admission. However, the nurse did not provide and finalize the updated evaluation prior to removing the medications from R1’s bedroom.

S1 stated that prior to removing R1’s medications from his/her room, the staff did not notify R1 or R1’s spouse and/or family member that R1’s medications would be removed. S1 admitted this to be a mistake as they should have notified R1 and R1’s responsible parties prior to removing the medications. R1’s spouse became upset with staff, in which staff returned R1’s medications.

Based on record review, R1’s service plan upon admission dated 12/30/2023 indicated that R1 was independent and did not require assistance with medication administration. It’s indicated that R1 could self-manage his/her medications. R1’s service plan was updated in July 2024. Based on R1’s physician’s report from January 2024, it stated that R1 had mild cognitive impairment and was able to administer own prescription medication, able to administer own PRN medication and able to store own medications. The review of records does not show any incidents concerning R1’s medication compliance and safety by storing his/her own medication. There were also no records from R1’s physician regarding the change of R1’s capacity to store his/her own medications or other diagnosis which would deem unsafe if R1 would store his/her medications. Page 2 of 3.