Complaint Investigation Report

It was alleged that staff is mishandling residents’ medication and staff is not administering residents’ medication as prescribed. It was reported that there have been medication errors due to facility staff administering wrong dosages and medications not administered as prescribed. During the medication review conducted on 03/17/2025, the LPAs did not identify any discrepancies in the medication records. All three (3) clients' medications and the Centrally Stored Medication and Destruction Records (CSMDR) were reviewed, and documentation indicated that medications are being administered as prescribed. The LPAs conducted pill counts for three (3) randomly selected clients, and the counts matched the corresponding documentation. During staff interviews, it was revealed that, during medication administration, staff read the medication name and dosage aloud to the clients. Staff reported that clients are responsible for removing their own medications from the packaging, while staff supervise to ensure accuracy and prevent errors. Additionally, staff stated that the pharmacy provides a copy of the CSMDR for each client’s routine medications. Client interviews corroborated with staff interviews as clients confirmed that they pop their medications themselves as staff read the instructions aloud. Furthermore, clients did not express any concerns regarding their medications. Based on the information obtained through medication review and observation, the Department has insufficient evidence to support the allegations of “staff is mishandling residents’ medication” and “staff is not administering residents’ medication as prescribed”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was also alleged that staff did not properly store medication. It was reported that medications were not being properly stored and secured. During the facility walkthrough, the LPA observed that the medication room was locked upon arrival. Additionally, inside the medication room, the medication cart was also observed to be locked. Interviews conducted with facility staff confirmed that the medication cart remains locked at all times, with the only exception being during active medication administration. Furthermore, the facility follows a schedule for distributing medications to clients during each shift. Based on LPA observations and interviews conducted, the Department has insufficient evidence to support the allegation of “staff did not properly store medication”. Therefore, this allegation is deemed Unsubstantiated at this time.