Complaint·September 28, 2023

INVESTIGATION REVEALED THE FOLLOWING: Allegation #6: Staff are not ensuring that resident receives medications as prescribed by their physician. The details of the complaint alleged that resident #1 (R1) may not be receiving medications as prescribed by the physician. The complainant reported due to (R1's) health condition it is suspected the doctor's prescribed medication orders are not being followed by staff. Service records revealed (R1) was admitted at Santa Fe Home Care II on 08/23/22 and was discharged on 09/18/23 according to administrator staff #1 (S1). (R1) was on hospice care and was being provided hospice care services twice a week. Pacific Post Acute Medical Records (dated: 08/23/22) listed (R1) was on (12) prescription medications. An interview between 10:01 am - 10:49 am with (2) out of (2) staff #2-#3 (S2-S3) confirmed that not knowing what a Medication Administrator Record (MAR) is for (R1). (S2) admitted that no medications were documented when administered to residents. (S2) confirmed that hospice did not assist with (R1's) medications and that only the staff at Santa Fe Home assisted. An interview with (S1) confirmed that staff assisted with medications for the residents and that the facility has a (MAR) on record but was unable to produce the records for the Department for review. The Department interviewed residents between 09:02 am - 12:00 pm (2) out (5) residents handled their medications residents #2 and #5 (R2 and R5). Three residents required assistance with medications residents #1, #3, and #4 (R1, R3, and R4). Physician's Report for (R1) (dated 08/05/22) indicated (R1) is not able to manage own prescription medications or able to administer own PRN medications. An interview with (R1) was conducted on 09/15/23, however, due to (R1's) health condition (R1) was not able to hold a conversation. The facility was not able to produce evidence of hospice records, resident's progress notes or (MAR) when requested. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Virginia Asis, Administrator, and a hard copy of the report along with appeal rights.