complaint·February 25, 2025

Records review revealed no incident reports for medication errors for R1 were documented. Electronic Medication Administration Record (EMAR) for R1 June 2024 revealed R1 had PRN medication prescribed to them which was recorded as given with the reason for giving the medication and the effectiveness of the dose recorded. Interview with (4) med tech staff revealed they were not aware of any medications errors for R1 and stated R1 obtained their PRN medication when needed. It was also alleged Resident #2 (R2) was given their medication twice May or June of 2024. Incident report dated 05/25/2024 revealed R2 was given Medication #1 (M1) twice due to a documentation error. The incident report stated Staff #1 (S1) had given Medication #1 (M1) at 6:00am to R2 and did not document it on the MAR before ending their shift. Another staff gave M1 to R2 after seeing M1 was not documented as given. The resident was placed on alert charting and monitored for any change in condition. Interview with S1 revealed they forgot to document M1 as given to R2 and another staff had given M1 again to R2 due to seeing M1 was not documented. An interview with R2 was unable to be conducted as R2 has since passed away. Interview with R2’s responsible party revealed there was an incident where R2 received M1 twice due to a staff member not properly recording the medication as given. The responsible party stated they were informed of the error and the resident did not suffer any adverse reactions. Therefore, based on LPA’s interviews conducted, and records reviewed the allegation that residents did not get their medication dispensed as prescribed is found to be substantiated for R2's medication error. The preponderance of the evidence standard has been met, therefore the above allegation is found to be substantiated at this time. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. June 2024 Staff Schedule and staff interviews revealed the NOC shift is from 10:00pm to 6:00am and is followed by the AM shift from 6:00am to 2:00pm. Staff interviews revealed residents are checked on every (2) hours unless they require additional checks per their incontinent needs and written assessment. R1’s Resident Assessment dated 06/18/2025 revealed R1 required to be checked on (4) times per shift, which equates to every (2) hours. Staff revealed changing of residents is not documented. An interview with R1 was unable to be conducted as R1 has since passed away. Interview with R1’s responsible party revealed they visited R1 around June of 2024 in the early morning and stated R1 was observed in soiled diaper and clothing occasionally. The responsible party estimated that R1 had not been change in (4) hours. They reported R1’s room was not observed to smell of urine or feces. Interview with (2) NOC shift staff working June of 2024 revealed R1 was never left in soiled clothing or diaper and could not recall a time where R1’s room smelled of feces or urine. LPA interviewed (3) AM shift staff working June of 2024 which revealed conflicting information. (1) staff interview revealed they were unaware of R1 being left in soiled clothing or diaper for an extended period of time or R1’s room being malodorous. (1) staff interview revealed they observed R1 in soiled clothing, sheets, and diaper and R1’s room was malodorous. This staff stated they reported this to the facility nurse Staff #2 (S2). Interview with S2 revealed they did not recall a time when R1 was left in soiled clothing or diaper. Therefore, the allegation that R1 was not changed for an extended period of time and that R1’s room was malodorous is found to be unsubstantiated. It was alleged “Staff do not ensure resident records are properly maintained” It was alleged that the narcotic medication counts for residents were not accounted for and the medication log for narcotic medication was being altered by staff June of 2024. LPA conducted interviews with (4) residents who resided at the facility June of 2024. The residents revealed they were unaware of the medications they were taking or if there were any medication errors with narcotic medications. LPA conducted (2) interviews with responsible parties for residents who resided at the facility June of 2024 who revealed they were unaware of any narcotic medication errors. LPA conducted interviews with (4) med tech staff who worked at the facility June of 2024. Staff interviews revealed narcotic medications are counted by med tech staff every shift and are recorded in the Electronic Medication Administration Record (EMAR) system by the supervising nurse in a narcotics medication Shift Change Log. Staff revealed the EMAR system accounts for any changes or edits made and were unaware of the logs were being altered. Interview with supervising nurse from June of 2024 denied the narcotics medication Shift Change Log was altered and stated all narcotics were accounted for. LPA requested the EMAR Narcotic log for (4) resident who resided at the facility June of 2024. The logs revealed the medication was accounted for every day of June 2024 with no discrepancies or documented changes. Therefore, the allegation that staff are not ensuring the resident’s medication records are maintained is found to be unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.