Complaint·April 2, 2024

Upon R1’s return, the facility received and reviewed the hospital documentation indicating the new allergic reaction to the exiting medication. Therefore, the facility should have discontinued the specific medication that caused the allergic reaction, removed the medication from the medication cart, and/or updated the MARs. Instead, the facility dispensed the medication causing the allergic reaction from 03/27/24 thru 04/01/24. Staff interviews confirmed they were aware the medication should have not been dispensed. However, staff stated R1 wanted the medication, therefore, it was dispensed to R1. Medications were not given as prescribed once the facility had knowledge to discontinue. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Business Office Manager, Monica Cordova whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names list to identify Resident #1] They discovered R1 on the floor and had R1 transported to the hospital. According to an internet search it takes approximately thirty (30) minutes for most medications to dissolve. Therefore, R1 would not have fallen within five (5) minutes of ingestion. R1’s interview revealed they took the medication and fell within minutes but did not believe it was a result of the medication. During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Business Office Manager, Monica Cordova whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names list to identify Resident #1]