The Royal Commission into Aged Care began in 2018. What that "forensic examination" found was widespread evidence of neglect and abuse in the aged care sector, with medication one of the top three concerns.
Others say it's not just about what medicine is being given out - but how it is administered.
Paul Versteege from the Combined Pensioners and Superannuants Association told the Royal Commission in 2019 it used to be the case that registered nurses handled medications all the time. But now, personal care staff often provide drugs to residents in what is called a Webster pack.
The pack is a small box that has individual compartments where pills can be stored for different days of the week.
"The medications that people need to take are supposed to be given to them by a nurse, at least an enrolled nurse, in some cases a registered nurse. But quite often... it's actually personal care workers that go around and look - well it's Tuesday morning so Mrs Johnson gets the pills that are in that little box."
But aged care providers see little issue with using medication devices. Paul Sadler is from the Aged and Community Care Providers Association [ACCPA], a group representing a range of major aged care providers.
