complaint·May 17, 2024

Medication Management. Document review revealed that after moving to Hallmark North home, Seroquel and Ativan were added to resident’s (R1) medication administration log for agitation. During staff interviews, it was reported that a staff person gave the resident an Ativan medication, as the resident was combative. After not calming down and approximately 30-40 minutes later, the staff person gave another type of medication, which was Seroquel. It was stated that the Seroquel was an “as needed” type of medication to calm the resident. It was reported that the resident appeared to be kind of “spacey and a little bit out of it.” It was reported in the last five years only one other resident was this agitated. During witness interviews, it was reported that on 2-10-24 a witness observed the resident in a chair with what seemed to be unconscious state, with her head bent in a way that looked painful. The witness stated when the care staff were asked about the unresponsive condition of resident, the staff responded, "I gave her the medication I was told to give her." The witness couldn't get the resident to respond appropriately, so they took the resident to the hospital where resident was diagnosed as “Over medicated.” Witness reported concern of residents overall sedated condition while in care at the facility. Witness stated previous to living at the facility the resident had been walking one to two miles daily. During the investigation process, it was determined that the facility staff administered the medication as prescribed by the physician; however, when the resident was taken to the hospital it was reported she was over medicated. The staff did not respond with appropriate assistance when observing the resident slumped over and barely responsive. The allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Exit interview conducted, a copy of the report, and appeal rights provided to administrator.