complaint·May 28, 2024

Allegation: “Medications are not being self-administered as prescribed:” The complaint alleges that medications for multiple residents are not administered as prescribed, including Resident #1 (R1) and Resident #2 (R2). LPA reviewed Medication Administration Records (MAR)s for R1 and R2. R1’s medication Docusate Sodium 100mg had a change in order effective 04/22/2022, when the medication changed from being administered once daily to twice a day. However, the medication is not marked as administered at all on 04/23/2022 and instead indicates “withheld per doctor order,” even though the new prescription was valid effective 04/22/2022. Then on 04/24/2022, the medication is only marked once daily under the prescription that was no longer valid. On 04/25/2022, this medication was marked as administered once on the prescription that was no longer valid and once under the new prescription. MAR review for R1 indicates Scopolamine 1mg patch was ordered “apply 1 patch transdermally behind an ear every 3 days (72 hours) for vertigo.” MAR is marked with this medication administered every day from 04/01/2022 to 04/30/2022, with the exception of 04/14/2022 and 04/15/2022 when R1 was out of the facility and on 04/23/2022 when the medication is marked as “medication unavailable.” It is unclear whether the medication was actually administered daily as initialed by staff or if the medication was given as prescribed and incorrectly marked on the MAR. Medications for Resident #3 (R3) reviewed contained additional inconsistencies. R3’s medication Docusate Sodium 100 mg softgel was prescribed “take one capsule twice daily for 3 days with a start date of 04/07/2022, but is marked as administered beginning on 04/12/2022 at 05:00PM, and marked twice daily through 04/28/2022 (with some exceptions), even though the stop date is listed as 04/26/2022 at 04:00PM. Based on record review, the allegation that “medications are not being administered as prescribed” is deemed SUBSTANTIATED at this time. Allegation: “Medications are not being refilled timely:” The complaint alleges that multiple residents medications are not being refilled on time, resulting in medications being unavailable to administer. LPA reviewed MAR printouts for multiple residents, including all those listed on the complaint allegation. MAR review revealed that R1’s medication polyethylene glycol indicates “medication unavailable” on 04/08/2022 and 04/09/2022. Multiple medications for R3 are marked as “medication unavailable” including R3’s Desoximetasone 0.25% cream, Guanfacine HCL ER 2mg tablet, Metformin HCL 500mg tablet, and Preservision. There were an additional 4 (four) medications for Resident Continued on LIC 9099-C #4 (R4) that were marked as unavailable during the same time period of 04/08/2022 to 04/10/2022, including R4’s Atorvastatin 40mg tablet, Diltiazem 30mg tablet, Meclizine 12.5mg caplet, and Xarelto 15mg tablet. Interview with medication staff revealed that the policy is to refill all medications when there are about 8 doses remaining to allow for sufficient time to receive the medications. However, on multiple occasions, including on the date of LPA KaSandra Lopez’s visit on 04/22/2022, there was only 1 dose remaining for many medications and refills had not yet been requested. Staff interviewed indicated this is a re-occurring concern that has been brought to management’s attention but has yet to be remedied. Therefore, based on interview and record review, the allegation that “medications are not being refilled timely” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted. Today’s reports and appeal rights were reviewed and provided via email. Allegation: “Facility staff gave a resident medication prescribed to another resident:” The complaint alleges that on many occasions, when a resident runs out of a medication, facility staff have used another resident’s medication in it’s place. LPA conducted interviews with staff, who all indicated they have never administered medications to one resident that are prescribed to another resident. Additionally, most staff interviewed had never heard of any other staff giving medications prescribed to one resident to another resident. Only one staff interviewed had heard of this happening, but this staff could not provide details as to a date this occurred, or which residents and medication were involved. Residents interviewed indicated medications are given on time and none are aware of any instances where they were given another resident’s medications. MAR records reviewed also did not have any indication of medications being shared amongst residents. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “facility staff gave a resident medication prescribed to another resident” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not trained properly:” The complaint alleges that staff working in the facility’s medication room have not received the appropriate training, both prior to beginning work as well as ongoing training requirements. LPA reviewed training records for 4 (four) medication technicians working in the facility at the time of the allegation. All 4 (four) of 4 (four) records reviewed did contain initial trainings for all staff, as well as ongoing trainings, both related to resident care as well as medication trainings. Staff interviewed indicated their training consists of both shadowing an experienced staff member, as well as computer trainings. Additionally, the facility conducts ongoing monthly in-service training for all staff. Specific medication technician ongoing trainings are also conducted on an as needed basis in addition to the monthly in-services. 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 “staff are not trained properly” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are sleeping during the overnight shift:” It was alleged that facility staff, particularly the NOC medication technician are sleeping during the overnight shift, rendering them unable to administer medications during their shift. LPA interviewed staff and residents. Interviews revealed that at the time of the complaint allegation, there were no residents taking regularly Report Continued on LIC 9099-C prescribed medications during the overnight shift. At that time, there were residents who requested PRN (as needed) medications regularly during the NOC shift. Residents interviewed indicated that while sometimes they do have to wait for a PRN (as needed) medication to be brought to them, they do not regularly have any problems or concerns getting their PRN medications. Staff interviewed have heard that staff do sleep on the NOC shift, but none interviewed had witnessed this occurring, nor had specific details on dates or staff involved. Management interviewed indicated they have showed up unannounced to audit the overnight shift and have not observed any staff sleeping during these audits. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff sleeping during the overnight shift” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff are not competent to provide the services necessary to meet resident needs:” Interview with both residents and facility staff revealed that facility staff are meeting the residents’ needs. Staff indicated they follow the care plans in place for each resident, and they regularly review the care plans to ensure there are no changes. When changes do occur with a resident’s services, the Health Services Director or the Memory Care Director discuss with the staff the additional services the resident now requires. Also, facility staff document on each resident’s care notes if there are any observed changes. These notes are reviewed during change of shift as well as by the Health Services Director in Assisted Living or the Memory Care Director. Facility staff are trained prior to providing care to the residents on individual residents’ care needs on the computer, with quizzes, and by shadowing experienced staff. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not competent to provide the services necessary to meet resident needs” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above complaint allegations. Exit interview conducted. A copy of the report was provided via email.