complaint·March 29, 2023

No update resident appraisal observed. LPA conducted interviews with four (4) out of four (4) staff on 11/07/2022, and Neptune Society staff, 11/08/2022. Investigator Ferris, conducted interviews with, witnesses (on 11/30/22), Primary Care Physician (on 12/19/22), nine (9) out of nine (9) staff members (on 11/30/22, 12/27/22. 12/28/22 and 12/29/22), Los Angeles County Department of Medical Examiner-Coroner-Investigator (on 01/26/23), and subpoenaed Los Angeles County Fire Department Response Repot and 911 Audio (on 12/15/22) and reviewed on 12/20/22. Allegation: Resident died due to staff administering the wrong medication The investigation findings revealed that R1 had been living at this facility since September 28, 2019. Although, R1 was able to independently ambulate throughout the facility, due to the use of full-time oxygen, R1 had a wheelchair as a backup (in case of fall or weakness). In addition, findings revealed that R1 was able to manage his/her own medications and due to R1’s changes in medical condition, R1’s responsible party requested the facility to start managing/storing R1’s medications as of October 1 st , 2022. During the Case Management Visit, conducted by LPA Panushkina on 11/07/22 at 12:05pm, LPA requested R1’s Centrally Stored Medications and Destruction Record (SCMDR) and observed no document was available. When LPA asked S3 why R1’s SCMDR record was left blank, S3 was unable to give an explanation and informed LPA that he/she just recently (as of October 2022) got hired. LPA also observed R1’s Appraisal Needs and Services Plan and or resident reappraisal, last dated on 06/30/2021, was not updated. During the course of investigation, LPA was also informed by S6 that although, S1 completed all required (by Oakmont) medication training, in September 2022, S1 expressed concerns numerous times to the staff and management about not being confident to independently administer medications to the residents and was scheduled to work without being provided an additional training/re-training. On 11/06/2022, S1 failed to ensure the medications were correctly dispensed and administered five (5) incorrect medications to resident (R1), which were prescribed to another resident (R2). Moreover, the facility failed to obtain timely medical attention for R1. Upon discovery that R1 was administered five (5) incorrect medications, staff was allegedly instructed to frequently check on R1 and obtain his/her "vitals", (i.e., R1’s blood pressure and oxygen saturation levels). First, no documentation was produced to show R1 was checked on at any time and no documentation was produced to show R1’s "vitals" were checked, upon Investigator Ferris’s request (on 11/30/22 and on 01/11/23). Continue on LIC9099-C Second, S3 provided names of staff, to Investigator Ferris, whom he/she instructed to check on R1. Those staff were interviewed by the Investigator and denied being instructed to check on R1, denied checking on R1, and denied knowledge of the incident. There was no documentation or statements made to show any measures were taken to decrease the potential for a negative outcome from the medication error. Finally, neither emergency medical services (911), R1's Primary Care Physician, Poison Control, nor R1's family were contacted immediately after discovering R1 was given five (5) incorrect medications and no medical attention or intervention of any kind was obtained for R1 prior to death. In addition, LPA reviewed the facility’s Medication Management-General Policy on 11/17/2022. According to the “Policy #7: The medication error must be investigated by the Health Services Director (HSD) or designee. The HSD will identify the appropriate follow-up, including the notification of the responsible party and healthcare practitioner.” Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting R1's death. The Licensee/Executive Director were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed, and delivered.