Complaint·August 1, 2023

Whinery was unable to provide LPA Moleski an incident report regarding an incident alleged by the complainant, during which staff allegedly did not respond timely to a call for assistance. LPA Moleski reviewed daily notes for R1 and did not find any indication that the incident alleged by the complainant occurred. LPA Moleski interviewed R1 and R1 said the incident alleged by the complainant “never happened.” The department has determined the following as it relates to the allegations that staff speak inappropriately in the presence of residents and that facility staff did not respond to residents call in a timely manner: Based on interviews with Whinery, S2-S7, and R1-R5, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was left with Whinery. A second incident report dated May 3, 2023 provided details regarding R1’s medication error. This incident report stated that R1 had an order to take a prescribed medication with a dose of “5 mg PO [per os] for 5 days skip 2 days,” but the doses being administered were “25 mg PO [per os] for 5 days and skipped 2 days.” The report states that “the resident was taking the wrong dose of 25 mg.” According to the incident report, the error was corrected after being discovered on April 27, 2023. During an interview, S1 said R1’s family members had brought in a 25 mg bottle of the medication, as R1 had previously been prescribed 25 mg doses. The facility accepted the bottle, but the discrepancy between dosage amounts on the bottle and on the prescription was not noticed by medication technicians prior to administration, according to S1. LPA Moleski reviewed three doctor’s orders for R6 and medication administration records (MARs) for R6 for the months of February through May 2023. The first order was dated January 19, 2023, and it discontinued a medication in 25 mg tablet form. The second order was dated January 25, 2023, and it ordered R6 to start 25 mg of the same medication in sprinkle form. The third order was dated May 15, 2023, and it discontinued the preceding prescription for that same medication. During an interview, S1 said the first discontinuation order dated January 19, 2023 was received and transferred correctly into R6’s MARs. The second order, which started the medication in sprinkle form, was not transferred into the MARs, according to S1. R6’s MARs showed R6 did not receive any dosages of this medication between February 13, 2023 and May 9, 2023. The medication was discontinued as of May 16, according to the MARs. The department has determined the following as it relates to the allegations that facility staff mismanaged residents’ medications: Based on interviews with S1 and based on review of resident records and incident reports, 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). An exit interview was held with Whinery. Appeal rights and a copy of this report was left with Whinery.