Complaint Investigation Report

Allegation: Staff did not ensure medication was dispensed as prescribed

During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of incident report dated 05/18/23 showed R1’s medications were not being administered as prescribed. A signed and dated medication list from R1’s primary care physician (PCP) indicated R1 should only be taking 75mg of a prescribed medication instead of the 150mg administered by staff. 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 not ensure medication was dispensed as prescribed was found to be substantiated.

Allegation: Staff did not ensure medication records were properly maintained

During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Director of Health Services (DHS) confirmed with LPA that facility staff did not make the proper changes in their electronic medication system (Quick Mar) after resident’s (R1) responsible party alerted them that the wrong dosage was charted and given to R1. DHS stated 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 not ensure medication records were properly maintained 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.