| Staff did not dispense medication to resident as prescribed.
It has been alleged by the Reporting Party (RP) that R1 was given the wrong medications and dosages for ‘almost 2 years.” RP states ‘for 22 months’ the facility did not update R1’s medications and doses from a third-party agency. The Department requested additional documentation regarding medications for R1, which RP did not provide.
The Department interviewed 13 Residents (R1 to R13). 7 Out 13 Residents stated he/she has no concerns with receiving his/her medications. R2, R4, R8 and R9 state he/she does not need assistance with medications. R7 and R13 did not respond to questions due to neurocognitive disorder.
The Department interviewed 4 Staff (S1 to S4). 3 Out of 4 staff state residents are receiving medications as prescribed. S4 states he/she is not a MedTech and does not know information about medications for residents. S1 states there was an incident in May 2025 involving a third-party agency for R1 requesting the facility adjusted R1’s medications. S1 states the third-party agency was told R1 needed a doctor’s order for any changes to medications. S1 state an updated medication order was received from R1’s physician after this incident. S1 states this incident was noted on R1’s progress notes.
The Department interviewed Witness 1 (W1). W1 states he/she does not have any concerns about the care his/her loved one is receiving at the facility.
Review of R1’s progress notes dated 6/19/2025 states on 6/10/2025 a third-party agency for R1 requested the facility change R1’s medication orders. On 6/11/2025 “new orders noted and carried out.” Review of R1’s medication dated 6/01/2025 to 6/30/2025 listed 4 medications updated on 6/11/2025.
On 9/25/2025 LPA conducted a random medication audit of 3 residents. LPAs reviewed medication bottles with the centrally stored logs, no discrepancies were noted during the medication audit.
Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation are UNSUBSTANTIATED.. An exit interview was conducted, and a copy of this report was provided.
Page 4 of 4
END OF REPORT |