Complaint·March 22, 2023

(CONTINUED FROM LIC9099) Both AM and PM doses were held on 12/16/22 and 12/17/22 and documented "withheld per DR/NP orders". There was no documentation done to show it as given or not given on 12/18/2022 AM and was documented as "withheld per DR/NP orders" for the 12/18/22 PM dose. However, the MAR then indicated Plaxovid was given to R1 for the 12/19/22 AM dose. On 12/20/22 and 12/21/22, all doses were "withheld per DR/NP orders". In total, R1's MARs indicated R1 was provided 14 doses of a 10 dose prescription. Review of R1's MARs revealed no documentation that R1 refused any doses of Plaxovid and interview with facility Resident Services Director (RSD) revealed R1 was not known to refuse medication. Per RSD, and inservice has already been conducted with all med tech staff regarding the importance of following up with every unmarked MAR dose or those marked with an exception, notifying the doctor and responsible party if any medication is refused, and ordering refills promptly. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.