Complaint·October 24, 2023

During that same visit, LPA Moleski observed signatures missing for nighttime doses of three medications listed for the evening of September 20, 2023, and for daytime doses of two medications for the morning of September 20, 2023. During a visit on October 5, 2023, LPA Moleski observed four of R1’s medication bottles empty. S1 said staff had called to order refills but the pharmacies were running late. One of these medications, a 30-tablet bottle of an antibiotic, was started on September 2, 2023, according to R1’s centrally stored medication records. R1 was to take one tablet daily. According to R1’s MARs, R1 was given a dose of this medication each day from September 2, 2023 through October 3, 2023. Based on the start date recorded in R1’s centrally stored medication records, and based on the doses recorded in R1’s MARs, this medication should have run out on September 31, 2023, not on October 3, 2023. During the same visit on October 5, 2023, LPA Moleski observed in R1’s centrally stored medication records that R1 started a 30-capsule bottle of medication on September 2, 2023. This medication was not listed on R1’s MARs for the month of September. LPA Moleski reviewed hospital discharge orders for R1 from a hospital visit dated August 21, 2023 to September 1, 2023 which discontinued the medication. On R1’s MARs for October 2023, R1 was given daily doses of the medication from October 1 to October 5, according to the MARs. During the same visit on October 5, 2023, LPA Moleski interviewed a staff member (S1). S1 said R1 was not given doses of the medication from October 1, 2023 through October 3, 2023, and admitted to falsely marking the MARs as if medication had been given, though none was. S1 said there was no new start order for the medication. LPA Moleski interviewed a second staff member (S2). S2 said R1 had been given doses of the discontinued medication on October 4, 2023 and October 5, 2023. During the same visit on October 5, 2023, LPA Moleski observed that only two capsules of the medication remained of the 30-capsule bottle. Based on doses signed off in R1’s MARs, a minimum of 25 capsules should have remained as of October 5, 2023. S1 said S1 flushed an unknown quantity of capsules at an unspecified date. S1 said there were no witnesses to this act. R1’s medication destruction records were blank as of October 5, 2023. [continued on 9099-C] The department has determined the following as it relates to the allegation that staff do not ensure that resident is administered their medication(s) according to physician's instructions: Based on interviews, record review, and observation, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 87465(a)(4). Due to being a repeat violation, a civil penalty in the amount of $250 was assessed. An exit interview was held with Lewis. Appeal rights and a copy of this report were left with staff member Eliesa Qiolele . The department has determined the following as it relates to the allegation that staff are discriminating against resident: Based on interviews, the above allegation is UNFOUNDED. A finding that the complaint allegation is unfounded means the allegation is false, could not have happened or is without a reasonable basis. An exit interview was held with Lewis and a copy of this report was left with staff member Eliesa Qiolele .