Complaint Investigation Report

Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with additional credible witnesses and other relevant parties. The following was then determined:

As to the allegation of, staff did not refill resident’s medication timely resulting in resident missing medication and staff are not giving residents medication as prescribed. It was alleged that, due to staff neglect and workload, Resident #1 (R1) ran out of blood thinner, eyedrops and bone density medication, leading to a two-day lapse in medication administration. Interviews with ED and RSD revealed that for residents who are unable to manage their own medications, the facility stores their medication in the Med-Room. Medication Technicians (Med-Techs) and nurses are jointly responsible for ensuring medication refills are processed in a timely manner. According to facility protocol, refill requests for external pharmacies are to be faxed 27 days in advanced, while those using the facility’s preferred pharmacy must be requested at least 14 days in advance. Interviews with R1 revealed that although the resident is able to communicate their needs clearly and follow instruction, they are not capable of independently managing or administering their prescribed medications. The investigation confirmed that a lapse in medication occurred because staff failed to send a refill request to the pharmacy in time. It was discovered through interviews that neither the Med-Techs, nor the RSD adhere to physician’s instructions regarding timely medication refills. As a result, of the failure to timely refill prescriptions, R1 missed scheduled daily doses of prescribed medication. During interviews, a Med-Tech revealed that the nurse on duty had verbally assumed responsibility for placing the refill order. However, upon request by the LPA, no written documentation could be produced to verify that the nurse or any other trained staff had faxed, emailed or otherwise contacted the pharmacy prior to the depletion of R1’s medication supply. Medication audits were conducted on 12/31/2024, 03/20/2025 and 04/10/2025. During these audits, pill counts, Medication Administration Record (MAR) and Centrally Stored Medication and Destruction Record (CSMDR) were reviewed for ten (10) randomly selected residents.