Incomplete Investigation of Medication-Related Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance related to medication administration and handling for a resident who had been readmitted with multiple diagnoses including Parkinson's disease, diabetes, hypothyroidism, pulmonary hypertension, and chronic kidney disease. A grievance filed on 8/2/25 documented that four medication cups labeled with this resident’s name were found at her bedside, while a review of her MAR for the same date showed that she had been documented as having received her medications. The grievance investigation and response completed on 8/4/25 stated that the residents involved had missed their medications, that the LPN involved had been educated, and that the provider was notified, but did not include additional information about the investigation. During an interview on 3/20/26, the Administrator stated there was no record of a medication error report or staff education related to medication storage, administration, or medications left at the resident’s bedside, and acknowledged that such documentation should have existed. This failure to conduct and document a complete investigation of the grievance, including the apparent discrepancy between the MAR and the medications found at the bedside, resulted in the facility not honoring the requirement to fully investigate and resolve resident grievances.
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