Complaint Investigation Report

Allegation: Staff mismanaged resident’s medication

During investigation, the department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. Review of R1’s hospital discharge summary report (AVS) dated 09/27/23 - 09/29/23 time stamped 6:53PM showed R1 was diagnosed with acute confusional state. Attending hospital physician prescribed new anti-psychotic medication, 25mg Risperidone to be taken by R1 2X per day with instructions to stop administering bedtime anti-psychotic medication called Seroquel (Quetiapine 25mg) along with other medications. Review of emails between Executive Director (ED) and responsible party (POA) dated 08/16/24 and 09/27/24 confirmed that R1’s 09/27/23 -09/29/23 hospital discharge report time stamped 6:53PM was mis-filed in another resident’s binder. R1 received Seroquel (Quetiapine) until October 3rd which was replaced by Risperidone on October 4th when staff reviewed and noted R1’s AVS report dated 09/27/23 -09/29/23 on 10/03/23. Another refill of R1’s Seroquel (Quetiapine 25mg) was filled by R1’s pharmacy in December 2023. Review of R1’s medication administration records (MARs) written 12/16/23 showed R1 was administered two anti-psychotic medications, Seroquel (Quetiapine 25mg) and Risperidone 25 mg from 12/16/23 until 01/22/24. LPA observed no medication re-evaluation was conducted in December 2023 with R1's primary care physician to clarify if medication list is still valid. 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 mismanaged resident’s medication was found to be substantiated.

Deficiency is 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.