I am afraid that I don't have a good answer for you. I know that there are imperfections in Showplan and sometimes information does not display fully accurately. In this case, I notice that there are a few more filter conditions on the DISPENSEEVENT table than just the CLIENTID. The remain predicates are filtered in the Key Lookup, which is just below the Index Seek. It is possible that the total estimate for the predicates is 1 row.
In any case, it seems to be that there is all reason to consider adding an index on (CLIENTID, MDEMEDICALGUIDANCESTATEID, DISPENSEEVENTPROCESSORIGINID, PARENTDISPENSEEVENTID, MDEAPPROVALSTATEID) INCLUDE (STATE). I need to add the caveat that I only see this query, and I don't know how dynamic these conditions are. That is, if this query exists in multiple permutations, it may not be wise to add indexes for all of them.