complaint·September 26, 2024

Continued from LIC 9099 Information gathered during the course of the investigation revealed that R1 resided at this facility from 06/24/2024 to 07/31/2024. On 08/02/2024, R1’s RP noticed a changed in condition and transported R1 to the hospital. The Centrally Stored Medication and Destruction Record (CSMDR) for R1 obtained and reviewed, reflected that R1 was prescribed Olanzapine once a day beginning in May 2024; however, the “Date Started” column was left incomplete by the facility as of 08/12/2024. Interview with Resident Care Coordinator revealed that the facility only assists with self-administration of medications based on the medication list signed by the physician and not what a resident brings during admission. LPAs reviewed R1 facility file and did not find a list of medication signed by any physician. Furthermore, LPAs requested Resident Care Coordinator and Med-Tech to provide a copy of the list of medication signed by R1’s physician, however neither the Resident Care Coordinator nor the Med-Tech on duty were able provide such document. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that R1 was not assisted with self-administration of medication. Therefore, the above allegation “Staff did not give resident medication as prescribed” is deemed SUBSTANTIATED at this time. It was also alleged that staff did not address a change in residents’ condition. It was reported R1’s Private Caregiver noticed blood in R1s underwear on 07/15/2024 and on 07/19/2024; however, the facility did not make any efforts to obtain any medical attention for R1 even after being notified. Information gathered reflected that R1's PC observed blood on R1’s underwear on 07/15/2024 and notified both the facility staff and R1’s RP. Additionally, R1 was also displaying mood changes such as agitation and distress. However, there is no documentation to support that the facility contacted R1’s Primary Care Physician (PCP) or attempted to obtain R1 any medical services. On 07/19/2024, after observing blood in R1’s underwear again, R1’s RP contacted Kaiser and R1 was diagnosed with a Urinary Tract Infection (UTI). Continued on LIC 9099-C Continued from LIC 9099-C LPAs interview with administrator revealed that administrator could not recall the incident occurring. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Staff did not address a change in residents’ condition” has been SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeal rights discussed, and a copy of report issued. Continued from LIC 9099 It was reported that "Staff did not safeguard residents' personal items". The RP's concern is that R1’s personal items have gone missing from their room. A file review revealed that the Client/Resident Personal Property and Valuables form (LIC621) which is use to itemize R1’s personal belongings, did not list the missing item. Furthermore, R1 never notified and/or divulged information to facility management and/or staff about updating or adding items to R1's LIC 621 since being admitted to the facility. As a result, there is no documented record of what personal property may have been present in R1’s room during the time of the alleged loss. Interview with staff revealed that staff will follow protocol, notifying the administrator immediately. Interviews with the administrator indicates that staff, residents, and sometimes responsible parties, do inform if an item goes missing. When this occurs, the staff will assist in searching for the missing item(s). Although the allegation may have happened or is valid, based on the interviews there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citation issued. Exit interview conducted, and a copy of report issued.