complaint·April 10, 2025

R1 was admitted to this facility on 12/1/24, according to R1’s admission agreement. R1 came to the facility with an order dated 11/25/24 to take one Oxycodone tablet every six hours as needed. Then, R1 received a change order to take one tablet by mouth twice per day dated 12/4/24. However, on 12/10/24, R1's physician changed the order again to be take two tablets every six hours as needed. R1's latest prescription for Oxycodone, dated 12/17/24, indicated that R1 was to take two tablets by mouth every six hours as needed, and one tablet twice daily. During an audit of R1’s medications on 12/20/24, LPA Moleski observed that R1 had a 60-tablet bottle of Oxycodone, which contained 27 tablets. The bottle was started on 12/5/24, according to R1’s centrally stored medication records. Both routine and PRN doses of the medication were drawn from this same 60-tablet bottle, according to Caridad. R1's MARs indicate R1 received routine doses of Oxycodone twice on Dec. 5 and 6, and once on Dec. 7, for a total of five doses. R1 visited the hospital later that day and remained hospitalized until Dec. 11. R1 received two routine doses of Oxycodone on Dec. 19, and once on the morning of Dec. 20. R1 received a total of eight daily doses of this medication between his admission date and the date of LPA Moleski’s medication audit on 12/20/24. R1's PRN MARs show doses of Oxycodone were given on Dec. 2 [1 tablet] Dec. 3. [1 tablet] Dec. 11 [2 tablets], Dec. 13 [1 tablet at 7:30 a.m. and 1 at 8 p.m.], Dec 14. [1 tablet at 8 a.m. and 1 tablet at 9 p.m.], Dec. 15 [an unknown dose at 9 a.m. and an unknown dose at 9 p.m.], Dec. 16 [an unknown dose at 9 a.m. and 2 tablets at 7 p.m.], Dec. 17 [an unknown dose at 9 a.m. and another unknown dose at 8 p.m.], Dec. 18 [an unknown dose at 4:30; a.m. or p.m. not recorded], Dec. 20 [1 tablet]. This totals 9 confirmed tablets were administered from the bottle opened on the 5th, and anywhere between 6 and 12 additional tablets were administered without a recorded dosage, presuming no more than two tablets were given at the intervals recorded. As stated above, R1 had a prescription order on file to take two tablets every six hours as needed, which means R1 should have been able to receive two tablets upon request, rather than one, starting from 12/10/24. [continued on 9099-C] Between the routine and PRN administrations as described above, R1 may have had anywhere between 23 and 29 total tablets administered between 12/5/24 and 12/20/24. This should have left anywhere between 31 and 37 tablets remaining in the bottle. However, there were 27 tablets remaining in the bottle as of 12/20/24. 22 CCR Section 87465(b)-(d) requires that, for any resident receiving PRN medications, there must be a physician’s note on file specifying the resident’s ability to determine their need for PRN medication, and their ability to communicate their symptoms. Licensees are not permitted to assist residents with self-administration of PRN medications without such a note on file and, unless the resident is determined to have no deficits in their ability to determine their own need for medication and their ability to communicate symptoms, licensees are required to maintain accurate records of dates, times, and dosages of all PRN medications given. R1 had no such note on file as of 12/20/24. According to R1’s LIC 602, R1 suffered from mild cognitive impairment, including confusion and disorientation. The department has determined the following as it relates to the allegation that facility staff are not giving a resident medication as needed: Based on interview, observation and record review, 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 hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Caridad. Appeal rights and a copy of this report were left with Caridad.