Complaint Investigation Report

The investigation revealed the following:

Regarding the allegation: " Staff did not provide proper medication assistance to resident in care.". It has been alleged t hat the above-mentioned facility could not store or administer proper comfort care medications. Interviews revealed that five (5) out of 5 staff and three (3) out of four (4) residents have denied the allegation, while one (1) resident was unable to provide a verbal or visual response.

Record reviews revealed that staff Aurora Ortiz (S3) was properly instructed by a skilled nurse regarding the appropriate administration of comfort care medications for resident one (R1) on 03/01/23 and that there was a stop in morphine administration on 04/11/23. On 05/25/23 R1's registered nurse from Kaiser Hospice (RN), made a visit to R1, upon which S3 was informed by RN to follow order as received. According to Medication Admissions Record (MAR), S3 provided one (1) dose on 05/25/23, 1 dose on 05/27/23, and 4 doses on 05/28/23. On 05/29/23 RN provided a new order for the medication to be administered every six (6) hours, around the clock, and to continue previous order of 1 dose every hour as needed. MAR noted around the clock doses began on 05/29/23.

Based on record reviews and interviews conducted, the preponderance of evidence standard has/has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with LaToya Johnson, Administrator, and a copy of this report has been provided.