Complaint Investigation Report

Allegation: “Medications are not being self-administered as prescribed:”

The complaint alleges that medications for multiple residents are not administered as prescribed, including Resident #1 (R1) and Resident #2 (R2). LPA reviewed Medication Administration Records (MAR)s for R1 and R2. R1’s medication Docusate Sodium 100mg had a change in order effective 04/22/2022, when the medication changed from being administered once daily to twice a day. However, the medication is not marked as administered at all on 04/23/2022 and instead indicates “withheld per doctor order,” even though the new prescription was valid effective 04/22/2022. Then on 04/24/2022, the medication is only marked once daily under the prescription that was no longer valid. On 04/25/2022, this medication was marked as administered once on the prescription that was no longer valid and once under the new prescription. MAR review for R1 indicates Scopolamine 1mg patch was ordered “apply 1 patch transdermally behind an ear every 3 days (72 hours) for vertigo.” MAR is marked with this medication administered every day from 04/01/2022 to 04/30/2022, with the exception of 04/14/2022 and 04/15/2022 when R1 was out of the facility and on 04/23/2022 when the medication is marked as “medication unavailable.” It is unclear whether the medication was actually administered daily as initialed by staff or if the medication was given as prescribed and incorrectly marked on the MAR. Medications for Resident #3 (R3) reviewed contained additional inconsistencies. R3’s medication Docusate Sodium 100 mg softgel was prescribed “take one capsule twice daily for 3 days with a start date of 04/07/2022, but is marked as administered beginning on 04/12/2022 at 05:00PM, and marked twice daily through 04/28/2022 (with some exceptions), even though the stop date is listed as 04/26/2022 at 04:00PM. Based on record review, the allegation that “medications are not being administered as prescribed” is deemed SUBSTANTIATED at this time.

Allegation: “Medications are not being refilled timely:”

The complaint alleges that multiple residents medications are not being refilled on time, resulting in medications being unavailable to administer. LPA reviewed MAR printouts for multiple residents, including all those listed on the complaint allegation. MAR review revealed that R1’s medication polyethylene glycol indicates “medication unavailable” on 04/08/2022 and 04/09/2022. Multiple medications for R3 are marked as “medication unavailable” including R3’s Desoximetasone 0.25% cream, Guanfacine HCL ER 2mg tablet, Metformin HCL 500mg tablet, and Preservision. There were an additional 4 (four) medications for Resident