Complaint Investigation Report

Allegation: Facility staff did not dispense medications as prescribed

The details of the complaint alleged that facility staff gave the wrong medication to C#1.

On 2/28/25, LPA Iniguez observed and reviewed (C#1)’s emergency discharge papers from Cedars Sinai-Marina del Rey Hospital dated 5/7/24. It is written that (C#1)’s diagnosis was chemical conjunctivitis of the right eye. In addition, on February 27, 2025, during records review, LPA Iniguez observed facility’s Plan of Operation/Client Medication Assistance Procedures, the plan stated that facility will adhere to these procedures including assisting with eye drops.

On May 13, 2024, the department conducted an Interview with the Administrator (A#1), she stated that (C#1)’s eye drops are kept in the refrigerator. The name of the prescribed eye drops is Rocklatan, which (C#1) uses one drop in both eyes at bedtime, and Combigan (C#1) uses one drop in both eyes twice daily. (A#1) stated the incident occurred during (C#1)’s bedtime dose when facility staff mistakenly administered ear drops instead of the prescribed eye drops. Upon realizing the error, facility staff and (C#1) called her. (A#1) asked facility staff to take (C#1) to Ocean Urgent Care. Urgent care staff advised them to go to the emergency room at Cedars-Sinai to have (C#1)’s eye flushed out. (A#1) stated that she promptly reported the special incident to the Regional Center, Community Care Licensing, and all appropriate agencies. (A#1) also confirmed that the facility staff is undergoing retraining.