Complaint Investigation Report

Patrick responded by text that the facility does not provide wheelchairs and that R1 was using a loaner wheelchair. Patrick stated that R1 no longer received Propylene Glycol after seeing R1's doctor. Patrick also stated that he spoke with staff and R1, and both confirmed that the 6:00 a.m. morphine was being given on time. Patrick reported that he set alarms to ensure medications were given on schedule.

LPA reviewed the MARs from June 1, 2025 through August 1, 2025. Review of the June 2025 MAR showed that Famotidine 20 mg, ordered once daily, was not given from June 12, 2025 through June 30, 2025 due to the medication being “not available at the facility.” Gabapentin 300 mg, ordered daily, was not given on June 30, 2025, as there was no staff initial recorded. Morphine 15 mg, ordered every 4 hours, was not given on June 29, 2025 at 12:00 a.m., as there was no staff initial recorded. Potassium Chloride ER 10 mq, ordered once daily, was not given on June 29 and June 30, 2025, as there were no staff initials recorded.

Review of the June 2025 MAR also showed that Miralax Powder (Propylene Glycol), ordered 17 grams once daily and to be held for loose stool, was documented as given daily from June 12, 2025 through June 30, 2025, as evidenced by staff initials. This documentation contradicts Patrick’s statement to family that R1 stopped taking this medication after doctor visit. Review of the July 2025 MAR showed that Miralax Powder continued to be given daily from July 1, 2025 through July 31, 2025, as evidenced by staff initials.

LPA also reviewed a medication order dated June 5, 2025, for Morphine Sulfate 15 mg, ordered to be given one tablet every 4 hours. However, the MAR indicated that Morphine 15 mg was being administered every 6 hours, as shown by the recorded staff initials. This indicates the medication was not administered according to the physician’s order.

Based on interviews and record review, the facility did not ensure medications were consistently available and administered as prescribed. In addition, there were discrepancies between staff statements and MAR documentation. Therefore, the allegation that staff did not provide medication assistance as prescribed is substantiated.

A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 9099D during this visit. Exit interview conducted and a copy of this report and appeal rights were provided via email.