Complaint Investigation Report

Allegation: Staff failed to administered medication as prescribed.

I t is alleged that staff failed to administered medication as prescribed. The complainant reported there have been too many medication errors for client #1 (C1). The complainant states most recent incidents were on 01/17/22 and 02/14/22 when seizure medications were either missed or given incorrectly. During this visit, staff #1 (S1) program director was interviewed and he indicated there were some medication errors and that incident reports were submitted to Community Care Licensing (CCL). The report also indicated that (C1's) conservators and Harbor Regional Center representatives were also notified. An interview with staff 2 (S2) who admitted and confirmed that she was responsible for the medication errors for both incidents on 01/17/22 and 02/14/22. (S2) claims she takes accountability for her actions and the errors were not done intentionally. (S2) claims on 01/17/22, she unintentionally did not administer two (2) prescribed medications for (C1) as she got distracted as during the time she was providing care for the clients a seismic event (earthquake) occurred and she was distracted and lost focus. The incident on 02/14/22 claims she just wanted to assist with the afternoon staff and gave the two (2) medications to (C1) earlier at 2 pm rather than at 4 pm as prescribed. (S2) claims she notified the program director of the errors immediately. (S1- S3) all reported no other clients were affected by medications errors or hospitalization was necessary due to the medications not being available or given at the wrong time. The Department received incident reports for both events regarding (C1). A review of Medication Administration Records for (C1) verifies the errors on 01/17/22 and 02/14/22. The Department reviewed client #1-#3 (C1-C3) service records and attempted to interview (C1-C2) who were present at the facility and were unable to hold a conversation as a result of their disability. (C3) was not available for an interview as he was at the hospital. Based on the information gathered there's sufficient evidence to corroborate the allegation mentioned above.

Based on observation, interviews, and record reviews, the preponderance of evidence standard has been met, therefore, the above allegation is found to be substantiated. According to California Code Regulations, Title 22 the deficiency issued is documented on LIC 9099-D.