complaint·January 26, 2023

Regarding the allegation “Resident was given the incorrect medication, resulting in hospitalization:” Woodland Hills Regional Office received an incident report via e-fax on 11/03/2022, which informed CCL of a medication error involving Resident #1 (R1) on 10/28/2022. The incident report indicates R1 received the incorrect medication, R1’s vitals were low, and R1 was transported to the hospital for evaluation. Incident report indicates that all parties were informed of the incident and that the resident had returned to care at the facility. A second incident report involving R1 and a medication error was received at the Woodland Hills Regional Office via e-fax on 01/13/2023 indicating R1 was given the incorrect dosage of their medication. The medication error had been discovered on 01/09/2023, however R1 had been receiving the incorrect dosage of the medication since 12/19/2022, when R1’s physician had changed the orders for that particular medication. All medication staff were retrained on medication administration and the facility’s corporate office audited all residents’ medications as a result. During the visit on 01/19/2023, LPA Dulek reviewed R1’s medications with ED Foerschner and medication technician. Review of R1’s medications revealed that R1’s medications had changed again and that the new medications are not labeled properly, as the prescription numbers do not match the electronic MAR. Additionally, R1’s prescription Trazodone HCl indicates a quantity of 15 pills were provided, however there are only 14 pills in the bubble pack, and it is an unopened bubble pack. LPA and ED discussed the pharmacy errors and LPA suggested utilizing a paper MAR when the documentation provided by the pharmacy does not match the prescription labels. Also discussed was ultimately, the facility has the responsibility of ensuring all medications are properly labeled and administered. Based on medication review, record review, and interview, the allegation “resident was given the incorrect medication, resulting in hospitalization” is deemed SUBSTANTIATED at this time. Regarding the allegation “Due to lack of care and supervision, resident sustained an injury:” It was alleged that during the overnight shift on 01/06/2023 – 01/07/2023, that R1 was unaccounted for and that during that time, R1 sustained a hematoma to the forehead. Incident report was received in the Woodland Hills Regional Office via e-fax on 01/13/2023 indicating R1 was witnessed coming out of another resident’s apartment and was observed with an abrasion above R1’s right eyebrow. R1 was unable to recall what had happened or how R1 sustained the injury. Initially, interview with facility management indicated that R1 had last been checked during staff rounds around 02:30AM on 01/07/2023 and was found around 06:00AM with the injury. However, staff interview revealed that Staff #1 (S1) was working alone in the Memory Care unit during the overnight shift. During the overnight (10:00PM – 06:00AM) shift, S1 had not checked on Report Continued on LIC 9099-C R1 at all. And since R1 does not take medications during the overnight shift, the medication technician working the entire building during the NOC shift had also not observed R1 during the shift. S1 had only been trained on 1 (one) of the 2 (two) care runs and therefore had only checked the residents in that care run during that shift. Interview also revealed that another resident was walking out of their room holding R1’s hand around 06:20AM and that is when Staff #2 (S2) discovered a large lump on R1’s head. R1’s Resident Assessment dated 11/21/2022 indicates “resident wakes up on some nights but is easily directed back to bed after ADL needs are met.” Resident Assessment also states, “resident wanders only within the common areas of the secured community....” Therefore, facility staff should have been aware that R1 does wander and requires assistance during the overnight shift. As thus, based on interview and record review, the allegation that “due to lack of care and supervision, resident sustained an injury” is deemed SUBSTANTIATED at this time. Regarding the allegation “Facility is understaffed:” It was alleged that during the overnight shift on 01/06/2023 – 01/07/2023, there was insufficient staffing to meet the needs of the residents. Interview revealed that typically there is one caregiver working in the Assisted Living unit and 2 caregivers working in the Memory Care unit, as well as one shared medication technician assisting with care needs in Assisted Living and medications throughout the building, totaling 4 care staff working the overnight shift in the facility. On the night of the incident involving R1, staff had called out of work, leaving one caregiver working in the Memory Care unit and a qualified member of the facility’s management team working as the shared medication technician. Interview revealed that there are at least 3 residents in the Memory Care unit that require a two person assist. The facility is continuing to work on hiring and training additional staff, but on the night of the incident involving R1, there was only one caregiver in the Memory Care unit to assist 23 residents. Therefore, based on interview, the allegation that “facility is understaffed” is deemed SUBSTANTIATED at this time. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.