Complaint·March 4, 2025

The facility reported medication technicians follow the QMAR when dispensing residents’ medications. Medication technicians are able to review a list of routine medications titled “Physician’s Orders” (POs) which are automatically generated from the QMAR. LPA reviewed the POs dated June 19, 2024, noting one (1) tablet of the medication in question is to be dispensed every morning thirty minutes before breakfast and one and a half tablets every Sunday morning thirty minutes before breakfast. LPA reviewed R1’s QMAR from October 2024 to March 2025. The QMAR dated October and November 2024 noted the medication in question was dispensed to R1 from October 1, 2024, to November 25, 2024, as directed in the POs dated June 19, 2024. LPA reviewed R1’s QMAR dated December 2024, which indicated one and a half tablets of the medication in question was dispensed to R1 every Sunday. R1’s QMAR dated December 2024 did not document the medication in question was dispensed to R1 daily. Two (2) staff interviewed reported medication technicians are instructed to create a paper Medication Administration Record (MAR) to document dispensing a medication that is active but for an unknown reason is not listed in the QMAR. The facility provided LPA with an undated paper MAR noting the daily dosage of the medication in question was only dispensed to R1 on the 28 th day of an unknown month. LPA reviewed R1’s physician’s orders from the Kaiser Permanent After Visit Summary (KPAVS) dated 12/26/24, noting one (1) tablet of the medication in question is to be dispensed every morning thirty minutes before breakfast and one and a half tablets every Sunday morning thirty minutes before breakfast. The facility reportedly faxed the KPAVS dated 12/26/24 to the pharmacy who entered R1’s medication orders in the QMAR. However, LPA reviewed the POs dated January 23, 2025, which noted only one and a half tablets of the medication in question to be dispensed every Sunday morning thirty minutes before breakfast. R1’s QMAR dated January 2025 corroborated the medication in question was only dispensed to R1 as directed in the January 23, 2025, POs. The facility searched but was unable to produce a paper MAR documenting the medication in question was dispensed to R1 daily in January 2025, as directed in the physician’s orders from R1's KPAVS dated 12/26/24. LPA reviewed the facility’s “Narrative Charting” noting R1 returned from the hospital on 2/23/25 and is to take the one tablet of the medication in question every morning and one and a half tablets every Sunday. LPA reviewed R1’s physician’s order from the KPAVS dated 2/23/25 noting the medication in question is to be administered one tablet every morning thirty minutes before breakfast and one and a half tablets every Sunday, with the next dose due on the morning of 2/24/25. LPA reviewed R1’s QMAR dated February 2025 which documented one and half tablets of the medication in question was dispensed to R1 on 2/2/25, 2/9/25, and 2/16/25 and one tablet daily beginning on 2/25/25. The QMAR dated February 2025 noted R1 was away from the facility from 2/18/25 to 2/24/25. One (1) of two (2) staff interviewed reported dispensing R1’s medication in question on 2/24/25 but was unable to produce a paper MAR to prove it. On 2/25/25, the Department received an incident report from the facility reporting on 2/17/25 R1 was sent to the emergency room due to being verbally unresponsive. LPA also reviewed R1’s Kaiser Permanente Progress Notes (KPPN) dated 3/3/25 noting R1 was recently hospitalized due to a medication error. The KPPN dated 3/3/25 noted R1’s medication in question was incorrectly entered into the care facility’s system and it was determined R1’s symptoms were due to lack of the medication in question. Health Services Associate, Carolina Campos reported supervisors are required to approve new medication orders entered onto the QMAR. The facility reportedly failed to verify the pharmacy entered the correct medication orders from the physician’s orders from R1’s KPAVS dated 12/26/2025, which reflected in the QMAR POs dated 1/23/2025 and resulted in the medication errors. One (1) of two (2) staff interviewed corroborated the allegation. R1 declined to be interviewed. Based on LPA’s interviews conducted and records reviewed, 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 9099 D. An exit interview was conducted, and a copy of this report was provided to Administrator Torres. *Note LPA was off-site from 1:05 p.m. to 1:35 p.m.