Complaint Investigation Report

Allegation: Medications not given to resident timely

The allegation alleges on 06/05/2021, staff only brought Resident #1 (R1) three of R1’s AM medications when R1 receives more than three AM medications. When R1 questioned where the other medications where, staff stated they would return with them. It was alleged after lunch, R1 still had not received the missed AM medications.

Medication record review revealed, R1 received ten (10) AM medication to be dispensed at 9:00 AM. Medication Passing Detail records for R1 on 06/05/2021, revealed R1 received six (6) of their AM medications at 9:00 AM and four (4) of their AM medications at 12:24 PM. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Medications not given to resident timely' is deemed Substantiated at this time.

Allegation: Staff mismanaged resident's medication

The allegation alleges R1 did not receive all their medications and facility staff acknowledged they failed to order R1's medications timely. Medication Passing Detail records for R1 revealed R1 did not receive two (2) AM medications on 06/06/2021 (Asprin and Losartan Pot 50 MG) due to the medication being on route for delivery. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff mismanaged resident's medication' is deemed Substantiated at this time.

Allegation: Staff does not respond to pendent calls timely

The allegation alleges residents have to wait 20 minutes or longer for staff to respond to pendent calls. During the investigation, the LPA interviewed six residents. Five out of the six residents interviewed used their pendent when they need assistance and reported they sometimes have to wait 20 minutes to over an hour for staff to respond to their call. Pendent call records were reviewed for 05/14/2021 through 06/14/2021 revealed the following. Report continued on LIC 9099-C.