Complaint Investigation Report

092700840-11-1-2021-25-AS-LMUZ-C8SPBL-20211115101031

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 520 COHASSET RD., STE. 170

This is an official report of an unannounced visit/investigation of a complaint received in our office on

05/20/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 25-AS-20210520151853

Staff administered medication to resident not prescribed by a physician

Staff did not seek medical attention for resident

Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore a mask and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Rod Fleeman.

Witness observed a notation on a MAR that was crossed out and noticed the resident was reportedly lethargic. No observable reaction or hospitalization. Resident was on hospice and on other narcotic medication. No direct witness that these allegations occurred. The identified party adamantly stated that the medication was never administered to the wrong resident, it was merely charted under the wrong resident and crossed out at the time of notation . Based on this, the allegation is UNSUBSTANTIATED.

As a result of this investigation, LPA finds the allegation that staff administered medication to resident not prescribed by a physician and staff did not seek medical attention for resident to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.