Complaint·August 22, 2023

R1 was sent to the hospital when they began experiencing shortness of breath and informed staff they could not breathe. During the investigation upon record review of R1s medical report R1 admitting diagnoses to the hospital on 02/25/2022 was Acute on chronic Hypercapnic and Hypoxemic Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD) Exacerbation, and Chronic Heart Failure with Preserved Ejection Fraction (HFPEF). At the time of the investigation LPA observed R1s physician report, their primary diagnoses are HRPEF and COPD. Based on interviews, observations, and record review there is not enough corroborating evidence to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED at the time of this investigation. #2. Staff sometimes administer medications directly into the residents mouth. It is alleged that staff stated that sometimes medication is placed directly into the resident’s mouth and sometimes they take it on their own. To investigate the above allegation, LPA began interviews with staff at approximately 2:16PM on 03/11/2022. Additional staff and resident interviews were conducted on 08/22/2023 at 11:33am between 1:10pm. Interviews with eight (08) out of (08) residents revealed they get their medication from the medication room or staff deliver it to their rooms. They receive their medication in a small cup or by a spoon which is placed in their hands, or they take it by spoon. They affirm they have not had their medication placed in their mouth by staff and have not witnessed staff place medication into another residents mouth. Interviews with S2 affirm they have never placed medication into a resident’s mouth, and they are aware residents have the right to refuse medication. S2 stated that R1 has tremors, and they would assist R1 with medication by placing their hand under R1 hand to prevent shaking. At the time of the investigation, LPA observed medication being distributed to residents in a cup then into their hand and the resident places their medication in their mouth. Upon record review of R1 physician report R1 is not able to administer their own prescription medication, and Cedar Sinai discharge summary R1 has tremors of the jaw and hands. Based on interviews, observations, and record review there is not enough corroborating evidence to prove that the alleged violation occurred. Therefore, the allegation is UNSUBSTANTIATED at the time of this investigation. No health and safety hazards are noted during this visit. No deficiencies cited. Exit interview conducted and copy of report and appeal rights issued.