Complaint·October 31, 2023

The Department conducted an initial complaint visit on 10/19/2020 and conducted additional complaint investigation visits on 07/09/2021, 08/23/2023, 10/03/2023, and 10/24/2023. R2’s Charting Notes from 07/11/2020 at 6:47 PM states, “Family member found medication of resident on the floor, family member asked if it could be crushed so it could be administered, explained it could not due to label specifications/instructions.” R3’s Hospice Team Care Plan indicates that R3 had a comfort pak that included orders to give 0.25 ml of Morphine Sulfate, Lorazepam 0.5 mg tablet every 6 hours for PRN for anxiety or agitation, and to call the hospice agency to initiate any comfort pak medication. R3’s Charting Notes entry from 01/08/2020 at 5:52 AM indicate that staff administered PRN of morphine to R3; the entry does not indicate if hospice was notified. R3’s Charting Notes from 01/08/2020 at 3:00 PM states, “[R3’s spouse] requests that we give small (0.25 ML) dose of morphine during waking hours and only use (0.5ML) dose during the night.” R3’s Charting Notes entry from 10/12/2020 2:00 PM stated R3 was given 0.25 ML of morphine and 0.5 MG of Lorazepam, but there is no statement about if the hospice agency was contacted prior to administering the comfort pak medications. On 10/24/2023, LPA Marrufo interviewed facility staff S1. During interview, S1 stated that staff are supposed to log that they have contacted the hospice care agency prior to initiating a comfort pak. S1 stated staff are not to take medication orders from families. On 10/03/2023, LPA Marrufo interviewed facility staff S2. During interview, S2 stated to have the job role as medication technician at the facility and was trained for almost two months in that role. S2 stated that before administering comfort paks, facility staff have to call the hospice agency and let the hospice agency know the resident’s condition. S2 stated the hospice agency will then let the staff know if the resident can use the comfort pak, which medication, and the dosage. S2 stated staff are supposed to chart the phone call with hospice care in the Medication Administration Record (MAR) in the resident’s chart notes. S2 stated if a family member asked if a resident could receive a comfort pak, staff would still need to contact the hospice agency first before administering the comfort pak. Page 2 of 3. LPA Marrufo obtained copies of R5 and R6s Charting Notes. The Charting Notes for R5 from 07/18/2023 and for R6 on 09/09/2023 both indicate that staff contacted the hospice agency prior to administering comfort paks. R2’s Charting Notes from 07/09/2020 at 5:34 AM states, “Before 3:30 am [R2] was pacing the hallways and a little agitated. Gave PRN.” The Charting Notes entry does not indicate which PRN was administered to R2 and if the hospice agency was notified. Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with Steven Silacci and a copy of the report and appeal rights were provided. Page 3 of 3. END REPORT S3 stated staff would also divert R4’s attention with various activities to prevent R4’s behaviors with feces. S3 stated to not remember if there was a time when facility staff were told R4 had ingested feces but staff did not respond. Administrator Steven Silacci stated S3 is the only staff at the facility who worked with R4 and is still employed at the facility. Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Steven Silacci and a copy of this report was provided. Page 2 of 2. END REPORT