Complaint Investigation Report

Allegation: Staff did not seek timely medical attention for a resident

Based on interviews and record reviews which were conducted, Executive Director (ED) confirmed with LPA that resident’s (R1) medication was ordered discontinued on 09/01/22. R1 was admitted to hospice care at the facility on 08/09/22. Staff notified R1’s hospice nurse about the medication error on 09/09/22 and an updated med list was requested. Hospice nurse visited R1 the same day and found R1’s vital signs good. However, R1 was administered a double dosage of the medication until 9/15/22 when the medication error was discovered by staff. R1’s family was notified by staff of the medication error on 09/17/22. Based on interviews and record reviews conducted, the allegation that staff did not seek timely medical attention for R1 is substantiated.

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

Exit interview conducted. Appeal Rights and a copy of this report provided.