Complaint Investigation Report

S1 stated that at 7:30 AM, they administered acetaminophen PRN medication to R1, followed by routine medications. R1 refused the pain patch at that time. R1 did not like patches or creams on their body because they felt cold. S1 stated they did not document the refusal immediately because they typically attempted administration again within the next hour. Shortly thereafter, R1 complained of shortness of breath, and 911 was called. S2 stated that R1 was given PRN pain medication in the morning. S2 further stated that R1 sometimes refused the pain patch initially but later agreed after further encouragement from staff or R1’s Responsible Person (FM1). The patch was typically applied at 8:00 AM and removed at 8:00 PM. S2 further stated R2’s pain medications were always given to R2. S3 stated they notified Med Tech whenever any resident complained of pain. S3 further stated that R1 was breathing heavily, which was why 911 was called. The Med tech called FM1, but FM1 refused to send R1 to the hospital when paramedics were there. S3 stated that around an hour later, R1 was breathing heavily again, and this time, FM1 agreed to send R1 to the hospital. S5 stated R2 always took their pain medications. S6 stated R2 never complained of pain. S7 stated they were R1’s primary caregiver and that pain medication had been administered in the morning. S7 did not recall whether R1 accepted the patch that morning. S7 stated that Med Tech called 911 because R1 was experiencing difficulty breathing.

LPA interviewed two residents (R3 and R4). Both R3 and R4 stated that prescribed medications were administered on time and that staff responded on time.

LPA interviewed R1’s Responsible Person (FM1). FM1 stated they did not have any concerns with the care provided to R1 at the facility, did not believe R1 was being neglected, and felt that the staff managed R1’s medications very well. FM1 stated that R1 was always in pain but never verbalized or requested pain medication. It was only when paramedics arrived that R1 expressed they were in pain; prior to that, R1 had not complained. FM1 further stated that the facility frequently communicated with them whenever R1 skipped a meal, refused medication, or when R1’s medications were running low. FM1 confirmed that they refused to have R1 transported to the hospital when paramedics arrived. However, after the paramedics left, after about an hour, when R1 began experiencing difficulty breathing again, FM1 agreed to have R1 sent to the hospital for evaluation.

On 06/04/2025, LPA reviewed R1’s and R2’s service plans. Based on LPA’s review, R1’s and R2’s service plans stated full assistance with the medication management.