Complaint Investigation Report

This page has been amended to revise the first paragraph.

Based on records review, Resident #1 (R1) was admitted to the facility on 5/20/2023. R1’s physician’s report shows R1 is not able to store and administer own medications. R1 is unable to manage own medications but can communicate the need for PRN medications .

Allegation: Staff did not provide resident with medications as prescribed.

It is alleged that staff did not provide resident with medications as prescribed. It was reported that staff has not been giving R1 a medication prescribed by the doctor. Based on interviews conducted, four staff (S1-S4) and two residents (R2 & R3), denied that staff did not provide resident with medications as prescribed. However, based on LPA’s records review, R1’s medication administration records (MAR) in May 2023 shows none of medications was administered. A record of each dose was not maintained in the resident's record. LPA observed R1’s MAR in May 2023 does not list R1’s nonprescription PRN medications. S2 stated S2 administered all R1’s medications since R1 moved into the facility on 5/24/2023 but S2 admitted that S2 forgot to update R1’s MAR and overlooked to list R1’s nonprescription PRN medications.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; Therefore, the allegation of: Staff did not provide resident with medications as prescribed” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Health and Safety Code), the following deficiency has been observed and citation issued (ref. LIC 9099D).

Exit interview was conducted and a copy of the report was provided to Administrator Teresita Bautista.