complaint·May 8, 2025

9099C-1.. Allegation: Resident was not administered medications as prescribed. The allegation states that resident (R1), who was under hospice care, was observed by visitors to be alert and talkative one day and the next day would be barely speaking, and almost in a coma state. The administrator stated (R1had a stroke and was paralyzed on the left side, would sometimes eat and drink lightly, "was fully aware of what's going on and did not have Dementia"The Administrator stated (R1) took "pre-filled meds" from their hospice company and was "very cooperative, and never refused medications. Additionally, the administrator stated that "two cousins visited everyday for 2-3 hours, there were a total of about ten different visitors, adding "the visitors never said anything that (R1) seemed over-medicated". The administrator confirmed the facility uses a Medication Administration Record (MAR), documents all PRN medications administered, and that (R1) took Ativan every (2) hours as well as Halidol. Staff (S1) confirmed that he helped with hospice medications, set up the medications per (R1's) chart, and (R1) "took her medications". (S1) stated (R1) was "normal, always sleepy", he assisted with pain medications and there were no problems. Staff (S2) confirmed that (R1) took Ativan and Halidol and there were no issues with medications being administered, asserting (R1) "surprised me at her age- she was in and out of lucid moments and at times didn't make sense". A family member who visited (R1) regularly stated (R1) did not like taking some of the medications- it was a challenge- (R1) did not like them". The family member explained "there were days where (R1) was adamant and didn't know who I was, and there were days when I called my cousin and said (R1) is not going to make it, and the next day (R1) was chipper". The family member stated "Some days (R1) seemed to be more heavily medicated than the other days- it was a roller coaster" and asked the nurse about the medications, who said she would follow up with facility staff to ensure the medications were being given at the proper time. The hospice nurse confirmed she spoke with the Administrator, at least twice, about how to correctly administer (R1's) medications by following the prescribed dosages. The nurse explained how the hospice Medical Director provided additional training on following the prescribed dosages, mainly with the medication, Ativan. The nurse indicated that the facility was administering medications correctly according to the prescribed frequency, but the mg/dosage was sometimes more or less than what was prescribed. *cont on 9099C-2.. 9099C-2 LPA reviewed medication documentation from November 2024- January 2025. The Centrally Stored Medication Record (LIC622) notes a prescription was filled on November 13, 2024 Lorazapem (Ativan) 0.5 mg tablet- One tablet to be given by mouth, every (6) hours as needed. On November 14, 2024, a new prescription of Ativan 1mg tablet (30 tablets) was logged for resident to take 1 tablet every (4) hours, as needed, for anxiety and agitation. On December 2, 2024, a refill bottle of Ativan 1mg (60) tablets was logged. The PRN log for November 2024 shows Ativan (quantity not listed) was administered once a day from November 14, 2024 through November 22, 2024 and was given again on November 26, 2024, once at 8:00 am and again at 9:00 pm. The PRN log for December 2024 notes 1 tablet of medication, Ativan was administered at least daily from December 1-5. LPA reviewed a hospice physician's order, dated December 6, 2024, where the order for Lorazapem (Ativan) 1 mg, every (4) hours was discontinued and an order for Ativan .5 mg, every 4 hours was started. The next administered doses were documented as follows: Dec 10- 9:00 am- 0.5 mg for restlessness Dec 11- 8:00 am- 1/2 tablet for restlessness and Dec 11- 5:00 pm- 1/2 tablet for restlessness Dec 12 7:30 am- 1/2 tablet for restlessness and Dec 12 5:30 pm- 1 tablet for restlessness Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview with the Administrator. Copy of report and appeal rights provided 9099A-C-1.. The administrator explained that the catheter was changed "three times by the hospice nurse due to leaking and that due to (R1's) bone structure" the nurse put tape to secure the catheter on the left side to secure it. The administrator stated (R1) "was very cognizant about what was going on and midnight was the last time she was checked until the morning". The hospice nurse stated (R1) definitely had Dementia and (R1) would tell stories that were not always credible. The hospice nurse indicated she did not believe (R1) was inappropriately touched by staff. Based on information obtained, LPA finds the allegation to be UNFOUNDED- -meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview. Copy of report provided.