complaint·May 10, 2022

Regarding the allegation: Staff failed to assist resident with the self-administration of medication It was alleged that R1 did not receive their medications. Today, the LPA reviewed the Medication Administration Record (MAR) for R1 for November 2021. The MAR revealed that R1 did not receive assistance with several medications due to the medication not being in the facility. The LPA observed that on the medication notes, staff indicated that medications were either ‘not available’ or ‘med not on hand’. For example, R1 had a missed dosage of Eliquis nine (9) times from 11/7/2021-11/14/2021; missed twelve (12) dosages of Magnesium Oxide, Vitamin D3, and Vitamin C, Vitamin B-12 from 11/6/2021 – 11/29/2021; and missed eleven (11) dosages of Senna from 11/7/2021 – 11/22/2021. Staff interviews confirmed that the staff whom assisted with R1 with the self-administration of medication are no longer working at this location. During today’s medication audit, the LPA audited medications for three residents. Two out of three residents (Resident #2, Resident #3) had PRN medications; however, the PRN medication documentation log was inaccurate. The facility plans to have a full medication audit completed by their regional nursing staff within the next two weeks. Based on the investigation, there is sufficient evidence to support the claim that the staff failed to assist resident with the self-administration of medication. This allegation is deemed Substantiated at this time. Regarding the allegation: Incomplete files It was alleged that the staff and resident files were incomplete. During the investigation, the LPA conducted a file audit on 12/10/2021 and during today’s visit. It was discovered that out of the thirteen (13) files audited, two out of thirteen staff needed valid first aid/CPR certification (S2, S3), one out of thirteen staff failed to have a completed job application on file (S1), and one out of thirteen staff needs a completed health screening (S2). However, staff communicated that they have been auditing files to ensure that all paperwork is in order. Based on the investigation, there is sufficient evidence to support the claim that the files were incomplete. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.