complaint·July 27, 2021

The investigation revealed the following: Allegation: Facility staff administered unprescribed medication to the resident. It is alleged the facility staff administered unprescribed medication to the resident. Based on LPA's records review, Resident #1 was admitted at the facility on 6/8/2018. Preplacement record shows Resident #1 needs help with his medication. According to the Medical Record/Physician’s Report, Resident #1 has dementia; not capable of dispensing his own medication; and not capable of medical decision due to his dementia; a list of his active prescribed medications does not include melatonin. Resident #1’s Medication Administration Record dated 6/1/2021-6/31/2021 does not show Melatonin as one of his prescribed medications. There is no record that melatonin was prescribed to Resident #1 by his doctor. Per LPA’s review of the alleged perpetrator’s (Staff #3) personnel record, she was hired on 4/6/2020 and completed eight hours of hands-on shadowing training and eight hours of other training or instructions. During LPA’s interview, Resident #1, who is the alleged victim, willingly showed up for interview but refused to answer the questions. LPA was unable to obtain information from him. Residents #2-#10 stated they were not given unprescribed medications and have not heard any other residents given or administered unprescribed medications. However, the Administrator (Staff #1) and the Director of Social Services (Staff #2) admitted that Resident #1 was given two white sleeping pills called melatonin (3 mg) not prescribed to him by this doctor. An incident report dated 7/2/2021 and interview with Staff #1 indicate that a Medication Technician (Staff #3) administered two tablets of melatonin on 6/30/2021 and soon later Resident #1 experienced a side effect that sounds like a hallucination. According to facility’s narrative charting, Staff #3 administered the melatonin to Resident #1 because she was not aware that melatonin is not a house medication. Report continued in LIC 9099C LPA attempted to interview Staff #3 over the telephone, but Staff #3 told LPA that she was not available for interview due to a personal reason. LPA was not able to obtain statements from Staff #3. Staff #1 stated she gave Staff #3 an in-service training on 7/2/2021 regarding mismanagement of medications. LPA’s interview with Resident #1’s Power of Attorney Representative (Witness #1) revealed that Resident #1 experienced a side effect of visual hallucination after taking the melatonin. Witness #1 stated Resident #1 informed her that in his hallucination, he felt like he turned white like a ghost then turned into a black man; he had bumps on his skin, he felt like he was beaten up, and his eyes were swollen. The interviews and records review concur with the above allegation. Based on LPA’s observations, interviews, and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An interview was conducted with Gwendolyn Craig, the Administrator, and a hard copy was provided along with Appeal rights.