Complaint Investigation Report

The allegation of “Staff do not distribute resident's medications as prescribed” alleges that facility staff do not distribute resident’s medications and place medications in an unlocked drawer for Resident #1 (R1) to retrieve themselves and do not supervise R1 when they take their medications. LPA Byrne observed the facility’s medication cabinet to be locked and R1’s medications to be centrally stored. LPA interviewed R1. R1 stated that facility staff will place their medication for the morning into a container and hand it to R1 to take. R1 confirmed that staff watch them take the medications and additionally confirmed that facility staff have not missed medication administration previously. LPA spoke with facility staff #1 (S1), S1 confirmed that they handle medication for the residents in the facility. S1 stated that it is procedure to keep the medications locked and inaccessible to clients in care. S1 confirmed that they secure the medications after distributing them to clients. LPA reviewed medications for two (2) residents. Both resident’s medications were documented appropriately on their centrally stored medication and destruction record sheets as well as on their respective medication administration record sheets. LPA confirmed that the medication count for two (2) residents matched what was documented on both sheets. Based on the information obtained during the physical plant tour, record review, and interviews there is not sufficient evidence to support the allegation of staff do not distribute resident's medications as prescribed. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Staff do not ensure that medications are stored locked and inaccessible to residents in care” alleges that facility staff do not ensure that resident medications are stored locked and inaccessible to residents in care. On both the 08/28/2024 visit and today’s visit (11/20/2024) LPA Byrne observed the facility’s medication cabinet to be locked and inaccessible to clients in care. LPA spoke with S1, S1 confirmed that they handle medication for the residents in the facility. S1 stated that it is procedure to keep the medications locked and inaccessible to clients in care. S1 confirmed that they secure the medications after distributing them to clients. LPA Byrne interviewed R1. R1 stated that they have not accessed the medication cabinet without staff present to distribute their medications. R1 confirmed that staff have never asked them to grab their medications from the closet alone. Based on the information obtained during the physical plant tour and interviews there is not sufficient evidence to support the allegation of staff do not ensure that medications are stored locked and inaccessible to residents in care. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.