complaint·March 30, 2023

On 02/11/2021, Licensing Program Analyst (LPA) Brian Balisi initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically at 11:00am with Elizabeth Flores, the facility Assistant Administrator. Between 12:30pm - 1pm LPA Basili conducted telephone interviews with the administrator and a video call which consisted of a review of physical plant. LPA also requested copies of Census, Staff schedule, admission agreement and resident documentation relevant to the investigation, to be emailed to the LPA by end of business day. On 2/12/2021, LPA Basili interviewed the complainant at 11:15am, and interviewed Administrator Elizabeth Flores between 12:30 p.m. to 1:00 p.m. On the allegation that the ‘Staff mismanaged resident's medication’; it is the complainant’s concern that on 01/23/2021, they went to the facility to pick up R1’s medication. The facility staff gave the complainant R1’s medications, and complainant was not asked to sign for the medications they received. Complainant took the medications to the hospital, and hospital staff found out that the facility staff gave the complainant another resident’s(R2) medication. To investigate the allegation LPA Urena interviewed the complainant on 03/10/2023 from 11:40 a.m. to 12:16 p.m. The interview revealed that one bottle of medicine for R2, was included in the bag of medicines for R1. LPA Basili interviewed Administrator Elizabeth Flores regarding contact protocols for residents being medication management. In regard to medication, the Administrator stated that they were informed by staff that R1’s POA came in to grab R1’s medication so they could take it to R1 in the hospital. Administrator was told by staff they gave them the medication. Assistant Administrator was not present at the time POA came to retrieve the medication. On 03/30/2023, LPA Urena interviewed staff #2(S2) and asked about the process for release of medication. The S2 stated that they use a form named Medication Transfer Sheet/Release of Responsible to release medication. LPAs Urena and Ascencio interviewed seven residents about assistance with their medication by the facilities med techs. Two out of seven residents stated that they had received medication that did not belong to them. The LPAs asked how they(residents) knew that the pills (medication) did not belong to them? R3 stated, ‘I know my pills, and I said to the med tech, I don’t take this, and I don’t recognize the pills’. R4 stated, ‘They gave me pills that didn’t belong to me, I told the med tech right away that they were not mine’. The LPAs conducted a medication audit for 57 residents, and the LPAs found one medication box (Methylprednisolone, 4mg), filed away under a wrong resident’s label. Per S2, the box of the medication did not fit in the assigned (labeled) for resident #8(R8). Additionally, the LPAs noticed that for resident #9(R9), the medication in the drawer did not have a divider nor label with R9’s name; for resident #10 (10) the divider was missing resident’s name. Based on the information obtained through interviews and record review, there is enough evidence to support the allegation that ‘Staff mismanaged resident's medication’. Therefore, this allegation is deemed Substantiated this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Citation was issued. Exit interview was conducted with Quality Assurance Director, Rafael Silva. A copy of the report and Appeal Rights were issued.