Complaint Investigation Report

Allegation: “Staff do not administer resident's medications in a timely manner:”

It was alleged that Resident #1 (R1)’s medications were administered up to 3 hours late at times. At the time of the allegation, R1 had moved out of the facility, so LPA was unable to review R1’s medications. However, LPA obtained R1’s Medication Administration Record (MAR) for the month of August 2021. MAR reviewed indicated R1’s medications were initialed as administered daily as prescribed until the date of R1’s move out, with the exception of R1’s Certrizine 5mg, which was marked as not administered, as the medication was unavailable. Staff interviewed indicated that medications scheduled at a certain time can be administered up to an hour prior to the scheduled time to an hour after the scheduled time. For example, if a medication is scheduled at 8:00AM, a medication technician could administer that medication anywhere from 07:00AM to 09:00AM and still be within an appropriate timeframe for medication assistance. Staff interviews revealed that if a medication was administered outside the appropriate timeframe, this would be reflected on the MAR as an exception, documented, and reported accordingly. Resident interviews revealed that medications are provided to the residents on time as prescribed. As R1 had moved out of the facility prior to the complaint investigation, LPA was unable to interview R1 or observe R1’s medications more thoroughly. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff do not administer resident’s medications in a timely manner” is deemed UNSUBSTANTIATED at this time.

Allegation: “Food service is inadequate:”

The complaint alleges that food was not provided to R1 for two (2) days. During an initial complaint visit, LPA obtained copies of the facility menu and foods offered. During an unrelated visit, LPA observed dinner service as well as food trays delivered to residents. LPA also observed lunch time in Memory Care during an annual visit. Each time LPA observed meals to be served to all residents in the dining room and in Memory Care. LPA observed the food in Memory Care is brought on a cart into the Memory Care unit and the care staff serve the residents the pre-plated foods. Residents have been seated at the table and the assigned care staff assist those who require feeding assistance. Staff interviews revealed that there are a few residents who prefer to stay in their rooms during mealtimes, particularly during the pandemic. Care staff hand deliver plates to those residents who choose to remain in their rooms. Staff interviewed could not recall a time when a Memory Care resident did not receive a meal or complained of not receiving a meal. Based on interview and Report Continued on LIC 9099-C