Complaint Investigation Report

During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of incident report dated 08/01/22 showed R1’s medications were not being administered as prescribed from 02/23/22 until 05/13/22. A signed and dated medication list from R1’s primary care physician (PCP) indicated R1 should only be taking 2 medications. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff overmedicated resident was found to be substantiated.

Allegation: Staff did not follow doctor’s orders

During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ED) who confirmed that medication errors occurred due to staff failing to contact R1’s authorized representative (POA) and primary care physician (PCP) in clarifying a change in the medication administration records which were accepted without proper verification of physician’s orders. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did follow doctor’s orders was found to be substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.