Complaint Investigation Report
The investigation revealed the following: Regarding allegation: Clients did not receive prescribed medication, Staff did not dispensed medication as prescribed, and Staff did not accurately document dispensed medication. It is alleged staff have incorrectly dispensed, incorrectly documented client’s medication, and client did not receive evening dose as pill was stuck in the bubble pack. Interviews conducted with clients revealed 2 out of 3 clients stated to receive medication and 1 out of the 2 stated is being provided medication properly. 1 out of 3 clients was unable to be interview due to cognitive skills. Interviews with staff revealed 3 out of 3 staff stated to have received training on medication administration. Staff dispenses the medication per prescription, and note the medication given in clients' medication sheet. Administrator stated there were unknown medication issues prior to her taking the role of administrator as of November 2022. In addition, all staff have been currently train and no medication issues have been currently noticed. During the visit on 11/22/22 LPA reviewed medication and medication sheets for the 3 clients and did not observe medication errors on medication sheets. Medication sheets were initialed by staff for each day. One pill was observed missing on bubble pack for November cycle for 11/30/22 for client #2 (C2)'s medication. Per staff it had been popped by error, the pill was disposed and a refill was requested from the pharmacy. The pill was observed in a bottle dispenser with proper label. Documents reviewed revealed staff received a competency test on medication guidelines at the time of employment and last medication administration training was provided on 4/23/23.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED .
Exit interview was conducted with Angela Williams - Administrator and a copy of this report will be email.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction