Complaint Investigation Report

Allegation #4: Staff mismanaged resident's medication.

The complaint detailed allegation of mismanagement regarding Resident #1's (R1's) medications by the staff. It has been reported that the facility issued pain medications and antifungal cream that were not authorized by R1's primary physician. Additionally, the facility authorized refills for medications from R1's former primary physician instead of the current physician. On November 2, 2024, R1 was admitted to the hospital, where it became evident that the facility had failed to administer necessary diabetic medications. This oversight raised significant concerns, especially since R1's blood glucose levels were not being consistently monitored, which is critical for effective diabetes management.

On November 2, 2024, R1 was admitted to Los Alamitos Medical Center for altered mental status caused by low blood sugar. An Unusual Incident Report from November 6, 2024, noted that R1 was feeling lightheaded in the dining area at 8:30 PM, just moments before the observation.

On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed five staff members (Staff #1 through Staff #5). All of them acknowledged that Resident #1 (R1) had been hospitalized due to general weakness. Staff #2 (S2) claimed that no one from the hospital inquired about R1's diabetic diagnosis. S2 was uncertain whether there had been any miscommunication regarding R1's prescribed medications with the pharmacy. Staff members S2 through S5 were aware that R1 had been receiving diabetic medications daily since their admission to the facility. They indicated that R1 was only receiving medications prescribed by R1's physician. Staff members S3 through S5 stated that the medication technicians were responsible for monitoring R1's blood glucose levels and that there should be a chart log documenting the daily results. However, Staff #1 (S1) claimed that R1’s service plan did not include care staff to monitor R1’s blood glucose levels.

On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 through Witness #5) regarding the allegation. One out of the five witnesses reported some discrepancies with medications being refilled, discontinued, or continued to be administered.