Complaint Investigation Report

The investigation reveals the following: Regarding " Staff mismanaged residents' medication", it is alleged that the facility mismanaged C1 and C2 medications. According to staff interviewed, C1 was using two (2) physicians with two (2) different pharmacy which led to a miscommunication with C1’s medication. C1’s Ambien was changed from a medication only being given as needed to a medication given routinely. The facility did not give the medication routinely due to either misplacing the medication or facility MAR’s not being updated. LPA reviewed the MARs for C1 and observed it not being written as a routine medication and still being considered as a PRN. LPA also observed there was no indication at C1’s Ambien was given the whole month of May. LPA observed C2’s MAR’s and observed that C2’s Clozaril was not given 5/5/204- 5/10/24. During medication review LPA observed missing medications or missing initials on medications that was given.

The investigation reveals the following: Regarding " Staff did not refill residents’ medication prescription in a timely manner.", it is alleged that C2 did not get a refill on Clozaril, a routine bedtime medication. The investigation reveals that night staff did not inform AM staff that C2’s medication needed a refill. When the facility tried to refill C2’s medication, the information was sent to the wrong pharmacy.

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit interview conducted with Administrator Gill Martinez and LVN Zean Montana. A copy of this record provided, and appeals rights given.