Complaint Investigation Report

It was alleged that facility staff did not dispense medications as prescribed. It was reported that Resident #1 (R1) was prescribed medications while living at the facility, but staff prevented R1 from taking their medications and did not dispense medications in accordance with physician’s orders. Record reviews and interviews conducted revealed that R1 preferred to attend doctor’s appointments either by themselves or with a family member, rather than with facility staff, as had been the usual practice in the past. Staff interviews indicated that R1 was bringing medications prescribed by their doctor; however, many of these medications lacked accompanying doctor’s orders or instructions. Communication records between facility staff and R1’s family member showed that staff had raised concerns about miscommunication regarding doctor’s appointments, new medications, and the discontinuation of medications. Additionally, facility staff frequently found extra pills or medications laying around R1’s bedroom that were not listed on R1’s centrally stored medications list. This prompted the facility staff to document these medications and add them to the centrally stored list, as well as to communicate with R1 and their family member, requesting that they share any new information about medications that staff was unaware of. During the medication review, the LPA did not find any discrepancies suggesting that medications are being administered as prescribed. Furthermore, interviews with residents confirmed that facility staff administer their medications daily, and no concerns were reported about the care received at the facility. Based on the information obtained during the course of the investigation, the Department has insufficient evidence to support the allegation of “facility staff did not dispense medications as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy issued.