complaint·October 6, 2021

Continued LIC9099-C page #2 R1 medications were not dispensed according to the resident’s physician's directions. R1 did not receive her correct dosage of medications. LPA Bunker requested pertinent documentation regarding the above allegation. (Physician's Report, Medical Administration Record, Admission agreement, Appraisal/Needs and Services Plan, Personnel Report, Resident's Roster, Special Incident Report, and Ongoing Medication Training) Allegation: Resident suffered a stroke from not receiving medications as prescribed. Interviews were conducted with S1-S2 and R1-R8. The Residents interviewed stated they were happy and had no problems at the facility and the Med Techs always dispense their medications according to their physician's directions. Staff stated this was a very busy time for the facility they were also dealing with the COVID-19 Pandemic outbreak. Staff stated R1 was a new resident they hadn't got her in their input MARS. They were waiting for her primary care doctor to send the order to CVS. R1 physicians weren't answering the telephone. They kept leaving messages with the receptionist because the doctor wasn't responding or returning their calls. Staff stated R1 missed one day of her Pradaxa medication on 12/13/2020. Staff stated on 12/16/2020 @ 9:30 P.M., the caregivers Imelda Nethercott and Christian Julia said it looked like R1 was having a stroke. The Medication Aide Katerina Williams immediately called 911, R1 was transported to UCLA Westwood. Executive Director Terri Weitzman stated she self-reported the incident to R1's family members and all the appropriate agencies in a timely manner within Title 22 Regulations required time frame. On 12/17/2020 R1's son who is a doctor had the prescription order filled for Pradaxa. Ms. Weitzman stated she waited at CVS pharmacy in Marina Del Rey, CA for the order and she pick up the medication for R1. Staff agrees R1 medication was not given according to her physician's directions. Based on LPA’s observations, interviews that were conducted, and records reviewed, 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, and Chapter 8 are being cited on the attached LIC9099-D. Appeal rights were discussed, and copies of LIC9099, LIC9099-C, and LIC9099-D was provided to the Executive Director (ED) Terri Weitzman. Exit interview conducted.