Complaint·December 12, 2024

Allegation: Staff did not ensure that resident had required oxygen administration Investigation Finding: Substantiated On 12/10/24 at 3:30PM, staff (S1, S2) confirmed with LPA that memory care hospice resident’s (R1) oxygen machine was turned off by S2 on 10/29/24 around 6:20PM because the machine emitted intermittent screeching sounds which agitated R1. S2 also stated that he/she removed R1’s oxygen mask and then left R1’s room that day. S1 stated that she was getting ready to go home around 6:30PM when she asked S2 how R1 was doing and S2 told her that he/she turned off R1’s oxygen machine and removed her oxygen mask. S2 stated she told S2 to call the hospice care team regarding the incident and immediately went to R1, turned the oxygen machine on and placed her oxygen mask on. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that resident had required oxygen administration. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Allegation: Staff mismanaged resident’s medication Investigation Finding: Substantiated On 12/10/24 at 4PM, staff (S1, S2) confirmed with LPA that hospice resident’s (R1) morphine medication was administered 2 hours late on 10/29/24. S2 stated he/she gave the morphine medication to S1 around 7PM instead of 5PM because he/she was waiting for R1’s medication dosage change orders which did not arrive on time. Review of R1’s medication administration records dated 10/29/24 showed R1’s morphine medication was to be administered every 4 hours as prescribed by the hospice care team for R1’s comfort care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff mismanaged resident’s medication. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Continued on next page, LIC 9099-C pg1 Allegation: Staff did not ensure that medication was inaccessible to others Investigation Finding: Substantiated On 12/10/24 at 4PM, staff (S1) confirmed with LPA that on 10/29/24 around 6:40PM, hospice resident’s (R1) morphine medication was left unattended on hospice resident’s (R1) side table in the presence of R1’s family members. S1 stated that she left the unopened morphine medication in R1’s room temporarily so she can take an important phone call from R1’s hospice care team for advice regarding the temporary removal of R1’s oxygen mask and oxygen machine turnoff. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not ensure that medication was inaccessible to others. The preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties . Exit interview conducted. Appeal Rights and a copy of this report provided.