Complaint Investigation Report

Due to staff negligence, resident missed medications.

The MAR review revealed the C medication was not administered on October first, second and seventh at 12p.m. MAR review revealed that the C medication was on administered on October sixth or ninth at 8p.m. The MAR review also revealed the C medication was not administered on October eight or ninth for 10p.m. shift, with no notations on MAR for missing medications.

During the investigation with staff interviews it was reported that medication was not given as the facility had run out of oral syringes. Staff five stated we did run out of oral syringes and I used one from house three, some of the other staff didn’t know to go borrow from house three, so the medication was not given.

Staff five stated there were medication technicians that were afraid to give R1 his pain medication, stating that it was too much. Staff four stated when R1’s medication was put in the computer incorrectly and medications were missed because they didn’t show up on his list of medications for R1. Staff four stated there was a few times R1 didn’t receive his medication as I was not trained in how to crush it and put it in a syringe.

Record review revealed the facility was out of stock for three of the residents’ medications, one of the medication was out of stock for seven days. Record review revealed multiple medications on multiple days were not recorded as given. Substantiated.

Due to lack of supervision, resident was wedged between the bed/wall in an unsafe situation.

It was reported that the resident was wedged between the wall and bed moaning in pain with no care staff insight.

Staff four stated R1 didn’t like his feet covered and he would kick his feet off the bed trying to get the blankets off of his feet. Staff three S3 stated I heard about that, S3 stated the bed was supposed to be up against the wall and locked. S3 stated the bed wasn’t locked because that is how R1 scooted between the bed and the wall. Staff six stated I’ve seen R1 get wedged more than once, he is trying to get to the chair. Substantiated.