complaint·August 13, 2021

Review of the LOA Medication Dosage Chart indicated the PRN medication was to be administered every six (6) hours as needed for agitation not to exceed four (4) dosages/24 hours. Per the facility’s Medication Administration Record, the PRN medication was not administered to the resident during the time R1’s episode of agitation and aggressive behavior on January 29, 2020. The “logged-in” comments entered in the MAR for January 29, 2020, indicated that R1 was OOF (out-of-facility). However, review of records established R1 was in the facility and that facility staff called 911 to assist with R1’s aggressive behavior. Interviews with multiple staff confirmed staff did have knowledge of R1’s aggressive behavior, including agitation, and described the de-escalation process in use which involved redirecting the resident to calm down. De-escalation attempted by staff was unsuccessful and situation escalated rapidly. A review of the 911 transcripts documented that the call was initiated at 3:23 PM and there was a 33-minute window from the time of the start of the incident at approximately 2:50 PM. Interviews with multiple staff confirmed R1 was not offered or given PRN medication during the episode on January 29, 2020. A review of the R1’s Nurses Notes revealed that R1’s behavior was a pattern which staff documented knowledge of R1’s history of episodes. A similar episode occurred on December 28, 2019, which staff acted and gave R1 PRN medication and continued to monitor R1. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside sources interviews and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Executive Director, Ashley Marcellus, and Deeanna Lyons, Director of Resident Care Services. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director, Ashley Marcellus, and Deeanna Lyons, Director of Resident Care Services via email. An electronic email receipt confirms the documents were received.