Complaint Investigation Report

Staff also confirmed that a pill was found on the counter the next morning. The pill matched one of the medications belonging to C1. Per staff interviewed, a staff in-service training was held today in response to the medication error. Staff stated the Medication Administration Records (MARs) are initialed immediately after they administer the medications. There is also a 15-minute post-med check conducted by another staff on duty to ensure medications are given as prescribed.

The three (3) clients interviewed do not know what medications they are taking, but stated that staff are administering them at their prescribed times. During the visit today, LPA reviewed medication for all three (3) clients and did observe any additional discrepancies/errors.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator. A copy of this report and appeal rights were provided.