Complaint Investigation Report

During the investigation process, parties that were involved were interviewed and it was reported that when the Physician’s Assistant (PA) was refilling prescriptions for the residents, she made a mistake and called the pharmacy with another resident's medication, and not the medication order for Resident 1. Shortly after the error, the PA realized her mistake, contacted the pharmacy, and canceled the prescription order error. In addition, it was stated that the medication order was never picked up.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.