complaint·December 12, 2024

Based on a review of the facility policies and procedures for medication management, facility staff classified as medication technicians were tasked with handling, dispensing, and documentation of the resident medications. It was learned that this facility employed an electronic medication administration record (E-MAR) system which required medication technicians to log in, verify that the medications corresponded to the correct resident, and initialed into this system after dispensing the medications to the residents in care. A review of this E-MAR system was conducted at this time. It was learned that there were facility residents who were prescribed narcotics by their attending licensed medical professional as well. Based on a review of the policies and procedures for handling, dispensing, and documentation of the resident narcotics, it was learned that the incoming shift would always conduct a count with the outgoing shift to make sure that the dispensed dates were correct, narcotics count numbers were aligned, and any changes or re-orders were addressed at that time. A review of the narcotics medication administration record was conducted at this time. It was learned that there were a total of 29 facility residents who did not require their medications to be centrally stored by this facility and it's staff. It was learned that these residents were deemed capable by their licensed medical professionals to be able to store and self care with their medications at this time. Based on interviews conducted during the course of this investigation, it was learned that there weren't any issues in regards to staff retaliating against facility residents at any time. It was learned that there have not been any incidents reported to this facility at this time. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred. There were no deficiencies observed or cited at this time. Exit Interview It was learned that for the caregivers currently employed at this facility, there were 11 put onto the AM shift (0600 to 1430 hours). It was learned that there were 10 put onto the PM shift (1400 to 2230 hours) and 4 scheduled for the NOC shift (2200 to 0630 hours). It was learned that of the 11 facility caregivers scheduled for the AM shift, only 9 of them were considered to be full time who were scheduled to work 4-5 days a week. It was learned that 1 caregiver split their days with the PM shift and another caregiver only worked the weekends (Saturday and Sunday) only. It was learned that there were 4 Medication Technicians scheduled for the AM shift (0630 to 1430 hours). There were 3 Medication Technicians who were scheduled for the PM shift (2230 to 0630 hours) but these individuals split their days and were also scheduled with the AM shift. It was learned that these Medication Technicians would work 2 days on the AM shift and then work 3 days for the PM shift. It was learned that there was currently only one Medication Technician scheduled for the NOC shift (2200 to 0630 hours) at this time. This medication technician for the NOC shift was only on schedule 4 days a week at this time. It was observed that there wasn't another medication technician scheduled at this time to cover the other 3 days for the NOC shift. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interview