complaint·March 24, 2023

Allegation: Staff are mismanaging resident's medications . It is alleged the facility began giving resident (R1) the wrong prescription medication dosage of "Rexulti" medication in October 2022. For many years the resident has had in place a physician order for Rexulti 4 mg. The findings indicate that R1 was assessed by the facility's in-house Psychiatrist on 9/19/2021, and as a result the medication dosage was changed from 4mg to 3mg. According to staff interviews, in September 2022, the facility Administrator asked med-tech staff (S1) for a list of residents in need of Psychiatrist care. The med-tech reviewed R1's chart and noted there was no Psychiatrist listed on the form. Therefore, assumed the resident did not have a Psychiatrist in place and referred the resident to the in-house Psychiatrist. After the resident was assessed, a lower prescription dosage was ordered by the in-house doctor on October 11, 2022. The resident began taking 3mg of Rexulti until January 14, 2023. In addition, R1 was prescribed melatonin for sleep cycle regulation, but per family request it was discharged on November 18, 2022. A total of five (5) residents were interviewed; of which none had knowledge of medication mismanagement. During today's, medication review LPA observed errors in MAR's records. Staff acknowledged the documentation errors. All staff interviewed confirmed R1's medications orders were mismanaged due to incomplete file records and lack of interdisciplinary team care coordination. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not get consent from responsible party for resident to see a different doctor. It is alleged that facility staff changed resident (R1's) Psychiatrist without responsible party's consent. Which resulted in medication errors due to record review oversight. Per staff interviews, a "Change of Primary Physician" form is to be completed and signed by the resident's responsible party whenever a doctor change is made. However, Administration staff did not notify and communicate with R1's responsible party, and proceeded to change R1's Psychiatrist to their in-house new Psychiatrist. All staff interviews confirmed the change was made without getting consent. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are cited according to California Code of Regulations, Title 22. See LIC 9099D. NOTE: Civil penalties are being assessed for repeat violations within the last 12 months. Exit interview was conducted with Wellness Nurse Elizabeth Contreras. A copy of the report and appeal rights were issued.