complaint·May 22, 2024

The documents received and reviewed are the Staff Roster, Resident Roster, resident’s Physician’s Reports, Residents Physicians Orders, and Resident Appraisals, and residents MARs (Medication Administration Records). INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff are not administering resident's medications as prescribed. It is alleged that staff failed to administer medications to a resident as prescribed. It is also alleged that a resident has had extended times without vital medications which have led to the resident experiencing extreme anxiety and hallucinations. 0n 05/22/24, the department audited residents MAR (dated: 02/01/24 - 02/29/24 and 03/01/24 - 03/31/24) and revealed that a Not Applicable note was noted for 18 out of 29 days in February and 11 out of 31 days in March. On 05/22/24 at 10:30 AM, (1) out of (8) staff that were interviewed by the Department were aware of the error. S8 admitted to knowing about the medication not being dispensed as prescribed to the resident. LPA Gonzalez asked S8, what happened on 03/15/24 and 03/16/24 with R1? S8 stated they couldn’t give the resident their medication those days because they were waiting on the refills. S8 stated that they wrote not applicable on the QuickMAR note section but forgot to note the reason for not applicable. LPA then asked S8 if the not applicable noted on the rest of the days in the MAR meant the same thing, and S8 stated that it did mean that the resident was not given their medication(s) as prescribed and said this won’t happen again. On 04/09/24, LPA Gonzalez interviewed residents #2 - #7 (R2 -R7). Five (5) out of six (6) residents interviewed stated that the staff at this facility dispense their medication as prescribed by their physician, and (6) out (6) residents interviewed stated they have not missed any medication dosage. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Continued on LIC9099-C Allegation: Staff are mismanaging resident’s medications. It is alleged that staff are mismanaging resident’s medications. It is also alleged that a resident had not had their Memantine medication in a week, because the medication was ordered but it had not arrived yet. On 04/09/24 LPA interviewed witness #1 (W1), R6’s daughter. Interview communicated that they feel there is not enough staff at this facility to provide for the needs of the residents. W1 stated that R6 does not get their medications on time or when needed. W1 stated that staff has advised them on several occasions that R6 did not get their medication because of the facility waiting for the medication to be refilled. On 05/22/24 at 10:30 AM, (1) out of (8) staff that were interviewed by the Department were aware of the error. S8 stated that they are aware the resident missed their medications on numerous times because they were out of medicine and were waiting on the medication to be refilled. S8 stated that in the past they have made the mistake of advising the nurse (which is responsible for refilling the resident’s medication) last minute or when the resident did not have any more medication, and that would cause a delay in receiving the new medication timely, which would cause the resident to go days without their medication(s). Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiencies have been observed and citations issued (ref. LIC 9099D). An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights was provided to Resident Services Director Neil Chandra.