complaint·June 30, 2021

Allegation: Staff mismanaged resident's medication. Based on observations made during record review and interviews conducted the findings indicate that on June 25, 2021 resident (R1) was not administered medications as directed. On 6/23/2021 and 6/24/2021 resident (R1) experienced vomiting and pain. Resident (R1's) doctor sent a physician order for two medications Cirpo and Zofram to the pharmacy. In addition, the facility failed to obtain R1’s aspirin 81 mg medication refill in advance. The aspirin medication was not administered on June 23 & 24. Facility med-tech staff stated the refills were received until June 25, 2021 at approximately 7:00 pm. However, the facility security guard received the medications. Med-tech staff (S2) did not ask security guard if R1's medications were received. Facility med-tech staff did not administer the medications to resident (R1) until the next day when med-staff (S4) found R1's medications in between 2 medication bins. NOTE: It is not the third party security guard's responsibility to receive or handle resident medications. Staff stated resident (R1's) medications were not refilled on time because the resident's doctor did send the physician order to the pharmacy in a timely manner. It was also revealed that due to facility staff shortages it is sometimes not possible to follow-up with doctor offices or pharmacies in order to check the status of the refills. During today's medication review a total of four (4) medication administration records were reviewed. Medication errors were observed for residents (R2-R4). Resident (R2) was missing 3 medications and two medications were observed but not listed on record. Per staff, the resident's medications have not been refilled because MD requested to see the resident prior to authorizing refills. Resident (R2) was missing one (1) medication and also had 6 medications pre-poured 3 days in advance. Resident (R3's) Clonidine .1 mg medication refill has not been received. Staff have not checked the status on the medication delivery. The facility does not have in place an electronic medication administration records system. Based on document review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 08. ***CIVIL PENALTY WAS ASSESSED An exit interview was conducted with Resident Care Coordinator Marina Galaviz and corporate staff Consultant Chia Demurjian and corporate witness Brenda Nicolas. A copy of the report an appeal rights were provided.