complaint·April 25, 2024

Allegation: Staff did not refill residents medication timely. It is alleged that on October 5, 2023 at approximately 9:30 PM, resident (R1's) blood sugar level was 534 because facility staff failed to reorder insulin medication. According to information obtained PM shift facility staff did not dispense the insulin medication before the resident's dinner meal, which resulted in a dangerous blood sugar level. A total of seven (7) staff were interviewed, which included the staff (S1) that was on shift on 10/5/23. Staff (S1) stated that R1's blood sugar was checked in the early afternoon hours and "it was high". Staff (S1) stated they went to the medication room and there was no insulin left, and the insulin order indicated "zero refills". Therefore, S1 called the pharmacy and they were not able to refill the medication without a current physician order. According to S1, they faxed R1's MD, but did not receive a response. Staff (S1) stated that they spoke to R1 and informed the resident that they could wait for the emergency insulin delivery and/or offered to transport the resident to the hospital. Staff acknowledged they waited "4 hours" to notify the Wellness Nurse and family because they were the only med-tech on duty in the PM shift. All staff interviewed acknowledged that the med-tech staff failed to order insulin medication when it was observed the resident was running low. According to facility protocol, med-techs are supposed to contact the doctor when medication refills are needed. Wellness Director acknowledged that med-tech staff knew the day before R1 ran out of insulin that a new order would be needed. It was stated that the AM med-tech staff should have ordered the insulin, but none of the staff documented the medications needed to be ordered. Family was contacted and they transported R1 to the hospital in order for the resident to be evaluated and so they could receive insulin medication. Facility staff did not call 911 emergency. The findings indicate med-tech staff failed to order R1's insulin medication after observing the insulin supply was running low. There is sufficient evidence to corroborate the allegation. Allegation: Staff gave resident another residents medication. It is alleged that on Sunday, October 29, 2023, med-tech staff (S2) dispensed four (4) wrong medications to resident (R1). According to information obtained, R1 was dispensed their evening medications, and also dispensed another resident's medications. Staff interviews revealed that staff (S1) left another resident's medications in R1's room, and asked other caregivers to check in on R1 and to get the other resident's medications that were left in the room. When staff (S2) went to the room, the other resident's medications were there, and staff assumed they belonged to R1. Therefore, S2 asked the resident to take their medications. According to interviews, staff (S2) misunderstood the instructions given by S1. Per file review, R1 has a diagnosis of early on-set Dementia. All staff interviewed acknowledged the medication error. Per facility protocol, staff cannot leave medications unlocked. Family was notified of medication error and transported the resident to the local hospital. Staff did not call 911 emergency. Therefore, staff negligence is corroborated. Allegation: Facility staff falsified documents. It is alleged that the incident report furnished upon request of R1's authorized representative pertaining to the October 5, 2023, in which med-tech staff failed to order and obtain insulin medication for R1 omitted the fact that insulin medication was not dispensed because the facility failed to refill and obtain a new physician order for the medication. LPA obtained a copy of the 2 incident reports provided to R1's authorized representative and compared it to what was submitted by staff to the Department of Social Services Community Care Licensing Division (CCLD) Regional Office. CCLD received a handwritten incident report completed by staff (S1), that stated that R1 wanted to be sent out to the hospital due to high blood sugar level readings, is waiting for insulin refill medication, and that paramedics were called and resident was transported to PIH Whittier Hospital. Staff (S1) stated that they called the paramedics for another resident and mistakenly mixed up the incidents. Med-techs, caregivers, and Wellness Director are in charge of filling out incident reports, which are then submitted to CCLD. In this case, the Wellness Director faxed the handwritten incident report that had incorrect information. A 2nd incident report was created and typed, and then provided to R1's authorized representative after family brought the false statements noted on the incident report to facility staff. However, the 2nd incident report was never faxed to CCLD. Therefore, there is sufficient evidence to corroborate that staff (S1) falsified documents. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Administrator Diana Bautista. A copy of the report and appeal rights were provided.