complaint·March 9, 2022

INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff administered incorrect medication for a resident while in care The complainant alleges that facility gave R1 incorrect dose of insulin. LPA reviewed facility documents, An order was received on 1/10/2022 changing R1’s medication dosages. LPA reviewed medication administration record and noted that for February of 2022, wrong dosage of medication was being administered to resident R1. LPA Cifuentes interviewed residents (R2-R6). R1 was unavailable for interview. Of those interviewed, one stated they took their medication themselves, three stated they had no issues with medications and one was unsure. LPA interviewed staff (S1-S4) regarding resident medications. All four staff stated they had heard of a resident being given incorrect medication. Based on information gathered, the Department did find sufficient evidence to support the allegation mentioned above. Allegation: Staff did not meeting a resident's diabetic needs while in care The complainant alleges that R1 blood sugar was not properly monitored during their time at facility, it should have been checked three times per day. LPA reviewed medication administration record for R1 for month of February, which only shows 6am blood sugar check routinely completed, the check before lunch only occurred 10 times and the check before dinner only occurred twice in the month. LPA spoke with residents (R2-R6) regarding the allegations. R1 was unavailable for interviews. Of those interviewed, two out of five stated they had diabetes, but there were no issues with their insulin. LPA Cifuentes interviewed staff (S1-S4) regarding diabetic residents. S2 stated residents blood sugar is always checked and logged in MAR. Based on information gathered, the Department did find sufficient evidence to support the allegation mentioned above. Based on information gathered, the department did find sufficient evidence to support allegations " Staff administered incorrect medication for a resident while in care,” and “Staff did not meeting a resident's diabetic needs while in care.” Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Social Services Elizabeth Hernandez