Complaint·July 6, 2023

It was reported via interviews that R1 had a drinking problem and that R1 was not present for their medication at the time the evening medications were distributed. Per OM, R1’s prescription did not include specific instructions such as not being able to take the pills after drinking alcohol. Despite their concerns about mixing the medication with alcohol, no proof could be found that the facility requested written instructions from R1’s physician regarding the resident mixing alcohol and medication. Per interviews conducted, staff admitted not administering R1’s medications when arriving to the facility late if intoxicated. Records reviewed by LPA Ramirez included the Medication Administration Record (MAR) dated April 2023 and May 2023 for R1. Per MAR for R1 the evening medications were either marked as Administered, Drug Refused and/or Absent from Facility. During the course of the interviews OM stated that R1 did not sign out of the facility during the times their MAR was marked as Absent from the facility and that R1’s Physician was verbally notified. During the investigation LPA reviewed documents including the Physician Order/Medication Review Report dated 12/15/2022 for R1. R1’s Physician Order/Medication Review does not include instruction and/or warnings regarding the prescribed medications. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility staff did not ensure that resident received prescribed medication while in care is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with OM Barba and a copy of this report along with the Appeal Rights were provided at the time of this visit.