Complaint Investigation Report

At 10:00 a.m., LPA requested and obtained copies of the following: Register of Facility Clients (LIC9020), facility's Personnel Report (LIC500) and four (4) of four (4) clients' Medical Assessments, Medication Administration Records (MAR), Centrally Stored Medication Records, and Individual Program Plans (IPP). At approximately 10:22 a.m., LPA interviewed the administrator, Staff#1 (S1) and C2. At 10:34 a.m., LPA reviewed four (4) of four (4) clients' centrally stored medication and medication records with the administrator present. At 12:00 pm., LPA initiated an interview with Staff #2 (S2) and Clients #4 (C4). At 1:03 p.m., LPA interviewed Staff #3(S3) by telephone. From 2:30 p.m. to 3:30 p.m., LPA reviewed the PRN or as needed medication for Client#1 (C1) and obtained copies of the facility's 15 Minute Medication check, PRN authorization form and daily notes for C1. LPA also interviewed Staff #4 (S4) and Staff #5 (S5), At 4:20 p.m., LPA interviewed C1.

Allegation: Staff are not administering medications to residents as prescribed. It was alleged that three (3) residents had missing medications in January. LPA's interview with the administrator revealed that medication for C2 was missing during the morning medication pass, however, the medication was delivered to the facility later that afternoon and provided the same day. LPA’s review of the MAR showed that staff had signed the initials for the day in question. According to the administrator, C3 was an emergency placement who had been in and out of hospitals, resulting in inconsistent pill counts. North Los Angeles County Regional Center was aware of this and provided guidance. A review of C1’s PRN medication indicated that one of two PRN medications was administered and documented on 01/05/26, which both staff and the administrator confirmed. LPA also observed that the bubble-pack medication for C1 was missing the dose for 01/06/26. Interviews with the administrator and all five (5) staff members interviewed could not clarify whether the 01/06/26 medication was administered to C1. C1 stated only that they took the PRN medication on 01/05/26. A review of C1’s PRN authorization form showed that C1 is unable to determine their own need for prescription or nonprescription PRN medication and is unable to clearly communicate symptoms. Staff reported that facility policy requires them to contact the administrator for approval before administering any PRN medication.

Based on interviews, the facility was unable to determine whether the missing January bubble-pack medication was administered to C1. Because both staff and the administrator have access to the medication, LPA could not determine when it went missing. Therefore the allegation is deemed Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 1 is cited on the attached LIC9099-D. Exit interview conducted. Copy of report provided to Daniel Morales.