complaint·April 25, 2022

During the subsequent complaint visit conducted on 05/27/2020, LPA Dulek conducted FaceTime video call to conduct a medication audit for Resident #1 (R1) and review of Resident #2 (R2)’s medication at 3:43PM. LPA observed that although Staff #1 (S1) stated that R1’s routine medication Atropine was discontinued as of Friday 5/22/2020, documentation on the MAR reflects the medication was administered at 5:00PM on 5/26/2020. S1 indicated this is an error on the electronic MAR, but there is handwritten documentation of the error. Handwritten documentation was unable to be provided to the LPA upon request. Additionally, R1’s Senna-Docusate was not initialed as administered on 5/13/2020 and 5/16/2020. Further review of the MAR pass notes indicates that on 5/14, 5/15, 5/18, 5/19, 5/20, and 5/21/2020 “waiting for med delivery.” Staff #1 (S1) indicated that the new pack of R1’s Senna Docusate was started on 5/20/2020 and LPA observed 21 pills remaining in the bubble pack. LPA Dulek requested a copy of the physician’s orders to discontinue R1’s daily Atropine and a copy of the medication destruction record for the Atropine. The LPA also requested a copy of the documentation indicating the electronic MAR error for R1’s Atropine on 5/26/2020. Administrator agreed to email all requested documentation by the end of business on 5/27/2020. Documentation was later discussed with the facility Executive Director, but no additional documentation was received. Therefore, based on record review and observation, the allegation that " Facility staff is not dispensing medication as prescribed " is deemed SUBSTANTIATED at this time. This allegation was previously substantiated for R1 and R2 on 03/25/2022 via complaint control # 29-AS-20200519123141. Therefore, no citation will be issued today. Exit interview conducted with Executive Director Kortnie Spitznogle. A copy of the report was provided via email. Regarding the allegation: "Facility staff did not notice a change in the resident's condition:" Record review revealed that Resident #1 (R1) was admitted to hospice 02/27/2020 and moved into the facility on 02/29/2020. R1 had a private caregiver working with them the entirety of the resident's stay at the facility. Hospice physician changed R1's orders based on R1's changes in condition. Care notes indicated that R1 was changed to a puree diet on 05/22/2020 as well as a medication change on this date. Records indicate when new orders were made through hospice, the orders were provided and reviewed with the facility staff. No additional significant change in condition was noted during R1's time residing at the facility. Interview with R1 and R2, who was R1's spouse, indicated staff are able to assist R1 out of bed and into a wheelchair. R1's physician's report dated 02/06/2020 indicates R1 is non-ambulatory. Care notes indicated R1 preferred to remain in bed, however there was no documentation that this was a change in condition rather than a preference. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore the allegation that "facility staff did not notice a change in the resident's condition" is deemed UNSUBSTANTIATED at this time. Regarding the allegation: "Facility staff do not allow resident to have guests:" At the time of the complaint, due to Coronovirus-19 (COVID-19) and to implement mitigation measures, Ventura County Public Health had issued orders for limited visitation in congregate living facilities. Public Health orders did allow for visitation for end of life situations and R1 was on hospice the entirety of their stay at the facility. Visitation logs were provided and reviewed for 5/18/2020 - 05/26/2020. Care notes reviewed indicated R1's family members called on 05/22/2020 and requested a visit with R1. Visitation logs indicate R1 had visitors signed into the facility on 05/23/2020. Interviews revealed that R1 did have a private caregiver daily and this private caregiver did not allow R1 additional visitors, but the facility was following Ventura County Public Health orders and did not restrict R1's guests. Based on interview and record review, although the allegation may be valid, there is insufficient evidence to prove a violation occurred, therefore the allegation that "facility staff do not allow resident to have guests" is deemed UNSUBSTANTIATED at this time. Exit interview conducted with Executive Director Kortnie Spitznogle. A copy of the report was provided via email.