complaint·July 23, 2021

1) Facility did not follow doctor's orders. Based on staff statements and R1's medication documents obtained, LPA determined that the above allegation occurred. R1's centrally stored medication log and narcotics log indicate a completed administration, on 9/30/2020, of the pain medication being question. Facility was unable to produce a discontinue order and confirmed that the medication order was active per the Medication Administration Record (MAR). During this period, R1 was also prescribed an alternate pain medication, which had an active order and was administered, and was recorded as effective on R1's MAR when it was given. 2) Facility did not notify POA regarding resident's change of condition. Based on statements, R1's incident report dated 11/11/2020, and facility's Fall Response Procedure, LPA determined that the above allegation occurred. R1 had an unwitnessed fall on 11/3/2020 and facility failed to notify responsible party immediately as stated in facility's Fall Response Procedure. R1's responsible party was verbally notified the following day when POA1 came to visit. Facility provided documentation that training was conducted on 11/10/2020 regarding facility's Fall Response Procedures; which includes the facility's reporting requirement. Based on LPA information obtained during investigation, 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, Chapter 8), are being cited on the attached LIC 9099D. Pharmacy delivery tracking document for R1's medication on 10/21/2020 states that S2 received the medication and signed for it. A comparison of the handwriting from the pharmacy's delivery service confirmation and S2's handwriting does not match. It is also noted that the name on the pharmacy's delivery service confirmation is spelled incorrectly. LPA is unable to determined if R1's medication were in fact delivered and/or if facility actually received them based on hand writing discrepancy, delivery time, and supporting documents from staff members. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of the report along with appeals rights were given.