complaint·October 26, 2022

The investigation revealed the following: Regarding the allegation… Facility staff did not dispense medication as prescribed. It’s being alleged that a resident did not receive a psychotropic medication for several days. LPA interviewed 5 out of 67 residents. 4 out of 5 denied the allegation. R2-5 all unanimously agreed that they have not had any issues with medication being given as prescribed. R1 states, “I was at the assisted living and they didn’t have my meds for 15 days. I was hallucinating. When I asked them where my meds were, they told me that they were short staff and they didn’t have time to order them.” During interviews with staff, LPA interviewed 4 out of 17 in total. 4 out of 4 could not confirm the allegation to be true. S1 states, “I wouldn’t know what really happened because I was out on leave during that time.” S2 states, “R1 may have missed the first two days of medication because we have to wait for the doctor to send the work orders.” S3 states, “There were no staff shortages while R1 was here. We went live with our new medical system Point Click Care (PCC) in April 2022. The staff are having some difficulties with the system and they are not clicking that they give the meds. They may have given it to R1, but they didn’t document it.” S4 denies ever giving meds to R1, “I’m not aware of R1 missing any medication. I don’t recall mentioning anything to them. I don’t recall giving R1 any meds.” During record review, LPA reviewed a staff schedule for the current month that coincides with the staff interviewed. LPA reviewed a resident roster, dated 10/19/2022, that coincides with the residents interviewed. LPA Agard reviewed the medication record for June and July 2022 for R1. LPA observed medication was given by S2 and S4. LPA observed, on some days, all medications was missed for several days during both months. This includes the specific psychotropic medication prescribed for daily administration. LPA observed it was not given during the first 20 days per the medication record review. Based on LPA’s observation, interviews conducted, and record review, 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 Chapter 8 is being cited (please see LIC9099D.) An exit interview was conducted. Plans of correction were developed. A copy of this report and appeal rights were given.