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. A review of clients’ medications and the Centrally Stored Medication and Destruction Records (CSMDR) revealed that medications are properly documented on the CSMDR. Interviews conducted with staff indicated that they hand the clients the medication bottle or bubble pack, and the clients self-administer their medications. Staff only document the medication as administered on the Medication Administration Records (MARs) after confirming that the client has taken the medication as prescribed. Additionally, staff reported that they review the CSMDR and MARs daily to ensure there are no medication errors. Interviews with clients confirmed that they are aware of their prescribed medications and dosages and expressed no concerns regarding receiving the wrong medication or dosage when assisted by facility staff. Based on the information obtained and reviewed, 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 are not being properly stored and locked up. During the facility walkthrough, the LPA observed that the medication cart is located inside the RPM’s office. Although the office was unlocked at the time due to the RPM being present, the medication cart was locked and inaccessible to clients. Interviews with facility staff confirmed that the medication cart remains locked at all times, except during active medication administration. Staff also stated that the office is kept locked whenever the RPM or their assistant is not physically present. Based on 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.