complaint·August 29, 2024

Continued from LIC9099... There were other incidents where the reporting party have observed frequently crushed R1’s time released Metoprolol, which could have killed R1. Per reporting party, staff was also observed R1 chewing extra-strength Tylenol after it was dispensed to resident. Based on interviews conducted with outside party, it was revealed that an outside agency was concerned regarding medications were properly given to R1 as prescribed by their doctor. LPA obtained hospice records confirming concerns regarding medication administration. Regarding crushing medication incidents, hospice records confirmed that as of 4/7/24, R1 received a physician’s verbal order to crush medications and on 4/10/24, R1’s physician followed up with a written doctor’s order allowing facility staff to crush medications and give with small amount of food or on a teaspoon. On 4/22/24 at 5:36pm, hospice records revealed that R1 did not receive their morning dosage of Seroquel, the hospice nurse spoke with staff who stated that R1 is on schedule to have Seroquel 150mg at 8am and 5pm, so they could not give it late, the facility will need the order to be changed and its medication was not given. Hospice nurse explained staff that the order indicates twice daily, but staff created dosing schedule. Order obtained supports twice daily with no time indicate. Therefore, facility staff did not dispense medication to resident as prescribed per doctor’s order. Based on facility records of Medication Administration Records dated 4/22/24 confirmed that Seroquel medication was not given to resident. 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), is being cited on the attached LIC 9099D. Appeal Rights Given. **Immediate Civil Penalty assessed in the amount of $250 for repeated violation within 12 months. Continued from LIC9099A... However, according to R1’s responsible party, they were not notified by the facility staff about the change of ambulatory status noticed on 3/30/24. The responsible party indicated that on 3/24/24, R1 was not observed needing to use a wheelchair to ambulate and the administrative assistant was refusing that R1 received hospice services, because they did not consider that R1 was dying. Although, R1’s physician report dated 2/6/24 indicates that R1 have a non-ambulatory status including dependency of mechanicals aids such as walkers and wheelchairs. On 4/2/24, the Department received an incident report informing that on 3/30/24 at 9pm, R1 was not doing well, facility staff contacted emergency medical responders (EMS) who assessed R1 and spoke with their responsible party who did not want R1 to go to the hospital, R1 did not go to the hospital, their responsible party notified R1’s physician and referral for hospice services was given. Hospice records revealed that on 3/30/24 staff stated that R1 has been ambulating independently. However, R1’s responsible party differs stating that R1 has been needing to a wheelchair occasionally for past few weeks. Hospice nurse observed R1 getting up independently and walk back to their room when hospice chaplain was visiting that afternoon. Hospice records indicated that on 4/1/24, R1 was observed ambulating independently through the facility. On 4/17/24, R1 was observed walking around the facility holding onto caregiver’s hand. Although, it is unclear to determine whether the facility staff have informed R1’s responsible party about both incidents. It was revealed that R1’s responsible party were aware of R1’s rapid health declining since 2020 due to progressive cognitive primarily in memory and executive function more than visuospatial. During interviews conducted with R1’s responsible party on 8/8/24 such information was also confirmed. A finding that the complaint allegation of staff did not inform resident's authorized representative of a change in resident's condition is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.