Complaint Investigation Report

Staff are not administering resident's medication per physician's order:

On 5/24/2023, LPA interviewed Executive Director (ED). ED stated Med Techs administer medications to residents. ED stated Med Techs will retry 3 times if residents refuse the medications. ED stated Med Techs will document and report if residents refuse medications.

LPA interviewed Director of Resident Service (S1). S1 stated resident R1 does not have any incident of missing medications.

LPA interviewed Executive Assistant (S2). S2 stated he/she is not aware of that R1 has incident of missing medications.

LPA toured resident room and interviewed resident R1. R1 was unable to exactly answer the questions. R1's family member (FM) stated R1 has neurocognitive impairment and he/she can help to answer the questions. LPA interviewed FM. FM stated on 5/7/2023 evening, he/she gave a bottle of medication to a staff (unknown name) in the facility hallway. FM stated based on R1's discharge document, the medication should be administered to R1 starting 5/8/2023. FM stated on 5/8/2023, he/she found the medication in the storage/medication room. FM stated on 5/8/2023, he/she met and talked to a nurse (S3) and the facility started to administer the medication to R1 on 5/13/2023. FM stated the facility did not administer the medication to R1 from 5/8/2023 to 5/12/2023.

LPA interviewed Medication Manager (S4). S4 stated R1 does not have incident of missing medications. S4 stated the system does not have the medication for R1 from 5/8/2023 to 5/12/2023. S4 stated the system has the medication starting 5/13/2023, and the MAR shows the medication was administered to R1 starting 5/13/2023. S4 stated only nurses and medication manager can input the medications into the computer system. S4 stated Med Techs administer medications to resident based on the medication information in the computer system. S4 stated the medication for R1 was entered in the computer system on 5/13/2023, and was administered to R1 staring on 5/132023. S4 stated he/she did not receive any report that the facility received R1's medication on 5/7/2023.