complaint·August 31, 2022

[CONTINUED FROM LIC 9099] According to interviews and facility records, R1 was diagnosed with Mild Cognitive Impairment and relied on facility staff for assistance with taking their prescribed medications. During the timeframe of the complaint allegation, R1 often attended an outpatient clinic twice per week. Based on R1’s blood tests, it was common for two specific medications to be adjusted/changed following clinic visits. On July 27, 2022, R1’s clinic physician determined that both of the said medications must now be given to R1 twice per day (instead of once per day). According to interviews of multiple outside sources, clinic staff faxed a signed valid order to the facility's nursing office, then phoned a supervisor there to confirm receipt and understanding. According to interview of Facility Supervisor #1 (S1), they received this faxed order on July 27, 2022, and told clinic staff that their team would implement the medication changes for R1 that same day. [Licensee thus had timely constructive knowledge of the orders]. According to interview of Facility Supervisor #2 (S2), they too saw the faxed order on July 27, 2022, as did S1. S1 and S2’s timely receipt was further corroborated in a phone text message between them about this specific order (the text message was date-stamped July 27, 2022). Staff interviews revealed that this faxed order was then placed a designated basket inside the facility’s nursing office, to be entered/transcribed into the facility’s medication management software. Ultimately, however, the order was not entered into the software as was expected (rather, it was subsequently misfiled elsewhere), a fact corroborated by S1, S2, and nursing department Staff #3 (S3). R1 thus received only half of the required dosage for two of their medications for three days; the errors which were discovered when R1 returned to the outpatient clinic on July 29, 2022. These facts were corroborated in follow-up E-mails that clinic staff sent to S1. [All parties, including R1 themselves, confirmed R1 suffered no adverse health event or injury due to said error(s)]. Clinic staff immediately contacted S1 by phone and fax to correct the errors. S1 told LPA they acknowledged a mistake had occurred and apologized to the clinic staff. By July 30, 2022, facility staff had resumed giving R1 both medications according to correct/prescribed amounts. Prior to CCLD receiving the complaint, S1 independently implemented a new routing procedure within the facility’s nursing office, with the goal of preventing future medications orders being overlooked. Aside from S1, LPA interviewed three other facility staff who distribute medications; all three consistently described the new office procedure that S1 established. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Based on interviews and records, the preponderance of evidence shows that on at least a few days, licensee did not give R1 two of their medications according to how they were prescribed. Licensee’s staff quick took action to correct and learn from the mistake, and were cooperative and forthcoming during CCLD’s investigation. The allegation, however, is substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Long and Jimenez, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.