Complaint Investigation Report

Allegation: Staff not providing accurate dosage of medications to resident

During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 was first admitted at the facility on 08/21/2021. Due to a change in condition, staff sent R1 to the hospital on 08/06/23, was admitted for treatment of physical deconditioning and discharged back to the facility on 08/12/23 with hospice care.

Administrator (ADM) and authorized representative (POA) agreed to implement R1’s written hospice care plan (comfort measures only) dated 08/12/23 prior to the initiation of R1’s hospice care. ADM implemented R1's hospice care plan starting 08/12/23 until 08/15/23. Review of hospice care’s physician’s order dated 08/15/23 show R1’s comfort drugs dosages were increased by the hospice care physician to manage R1’s pain and anxiety. LPA interviewed ADM who stated that she refused to implement R1’s increased comfort drug dosages on 08/16/23 because she is a hospice nurse and did not believe in the hospice physician’s assessment. POA and family had to implement hospice doctor’s orders for increased comfort drug dosages until R1 passed on 08/19/23. 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 was not providing accurate dosage of medications to resident 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.