complaint·April 5, 2021

The investigation revealed the following: Staff yell at residents R1 stated that S1 and S2 yell at residents. During observations, LPA observed staff speaking calmly to residents. During interviews, S1 and S2 stated that they may have to yell with residents who are hard of hearing but never yell out of anger. S3 stated that she has heard of a resident complaining that staff yells but has not witnessed it. S4 stated that S2 has a strong voice but has not personally heard her yell at residents. 2 out of 3 residents (R1 & R6) stated that staff yell at them loudly on a consistent basis and stated that they are not hard of hearing. A review of the Needs and Services plan for R1 confirms that R1 is not hard of hearing. Staff did not follow Dr. orders A review of R1's prescription shows that the medication Northea and Midodrine is to be taken 3 times daily at 2 a.m., 5:30 a.m., and 2 p.m. Interview with R1's nurse practitioner (NP) confirmed that the prescription times listed is correct. The NP said that on 8/17/20 he adjusted the prescription to list the times to take the medication. NP stated that he adjusted it because the patient wanted specific times written on the prescription so that the caregivers would give him the medications at the same time each day to avoid dizzy spells. A review of the MAR logs showed that the medications Northea and Midodrine was provided three times daily but not at a specified time as listed on the prescription. Staff stated that they gave R1 the medications as prescribed 3 times daily but R1 stated that the caregivers did not want to give him the medication at 2 a.m. S1 and S2 stated that they did not give R1 the medication at 2 a.m. because the resident was independent and could take the medication on his own. S3 stated the staff gave him all of his medications except for insulin which was self administered. S4 stated that there was a dispute about the medications because S2 said that the prescription times were wrong and she needed to call the doctor to verify. She stated R1 got mad because they would not follow the prescription orders. Based on interviews, observation, and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. CCR Title 22, Division 6, Chapter 8 is being cited on attached LIC9099D. An exit interview was conducted and copy of this report and appeal rights provided.