Complaint·February 21, 2023

As part of the investigation, LPA interviewed former administrator, facility staff, and reviewed documentation. According to the former administrator, the medications were not administered to R1 because medications were not delivered by the pharmacy. According to staff #1 (S1), the refills for the medications were sent to the pharmacy 2 days prior to running out but the medications were not delivered on time. Therefore S1 followed up with the pharmacy on 10/10/2022 and S1 was told that there was no refills and in order for the medication to be delivered, they needed a new physician's order for the refill. Therefore, on the same day, S1 faxed an order to R1's physician requesting a refill. S1 stated that S1 continued to follow-up on R1's medications as they were not delivered but S1 did not remember if the interactions were documented. In addition, S1 stated that this matter was discovered by a former staff on 10/17/2022, and this former staff acted on it and the medications were delivered within 2 days. According to staff #2 (S2) , the medication was not administered as the facility was waiting for the physician to approve the refill and S2 did not follow-up with the physician and the pharmacy while waiting for the medications. According to staff #3 (S3), the medication was not administered as the medication was not available and S3 can't not remember if S3 followed up while waiting for the medications. Based on R1's electronic medication administration records, medication #1 from 10/10/2022 5:00PM to 10/18/2022 8AM are initialed and circled and medication #2 from 10/16/2022 5:00PM - 10/18/2022 5PM are also initialed and circled. According to former administrator, circles around facility staff initials is an indication that the medications were not given on those days and times. In addition, the electronic medication administration records revealed that the reasons the medications were not administered on the above dates and times were due no refills, waiting for refills, and waiting for medication; the facility was not able to provide additional documentation indicating follow-up attempts made by facility staff until a note from a former staff on 10/17/2022 at 11:30am indicating that this matter was discovered by this former staff on 10/17/2022 and this staff took necessary actions to resolve the matter. The medication arrived on 10/20/2022 and it was administered to R1 with one of the medication being a higher dosage. Based on record reviews, and interviews during the course of the investigation, this allegation is deemed to be substantiated as the facility was not able to provide proof that facility staff followed up on R1's medication from 10/11/2022 - 10/16/2022, which resulted in delaying of medications being delivered and administered. Based on interviews, observations and record review during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, A copy is provided and Appeal Rights provided LPA interviewed 4 facility staff who assists residents with self-administration of medication and all of them were able to articulate the procedures when a prescribed medication is available for administration. Facility provided a staff sign-in record of a recent in-service that was conducted on 10/27/2022 by the directors on medication related topics. Based on interviews, observations and record reviews during the course of the investigation, this allegation is deemed to be unsubstantiated as the facility was able to articulate the proper procedures when the medication is not delivered by the pharmacy on time. However, the facility staff failed to follow up on the procedures as they described which resulted a longer delay of the medications being available for R1 and this finding is cited on LIC 9099 and LIC 9099D. This report is reviewed and discussed with the administrator. A copy is provided.