Complaint Investigation Report

The investigation revealed the following:

Regarding Allegation #1 : Facility did not ensure that resident received prescribed medications.

This complaint alleged that staff did not have prescribed insulin or metformin for C1 use. On 10/12/2023 LPA Calderon obtained and reviewed the physician order (dated 09/23/2023 and 10/04/2023). The prescription order indicated taking one 500 mg Metformin tablet by mouth twice a day with morning and evening meals. Medication Administration Record (MAR) for C1 noted that Metformin was given to C1 from 10/01/2023 to 10/08/2023. LPA Calderon interviewed with A1. A1 stated that C1 was a client from 09/28/2023 to 10/08/2023. A1 reported that C1 did not arrive at the facility with insulin or Metformin. A1 claimed that staff ordered Metformin for C1 on 09/23/2023 and 10/04/2023. LPA Interviewed with S1. S1 stated that S1 reviewed C1’s medical records and Metformin was ordered on 09/23/2023 and based on the (MAR), Metformin was given to C1 from 10/01/2023 to 10/08/2023. LPA Calderon could not interview C1 as C1 moved out of the facility on 10/08/2023 and did not have forwarding contact information. C2 is non-verbal so no interview was available. An interview with C3 reported that staff has never run out of C3’s medications and has never missed giving C3 medications timely. Based on the information gathered, C1 who was admitted on 09/28/23 was not assisted with prescription medications until 10/01/23. C1 did not have the required Metformin and insulin for 09/28/23 through 9/30/23. Therefore, there is sufficient evidence to support this allegation mentioned above.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citations issued (ref LIC9099D).

An exit interview was conducted and copy of the Complaint Report was provided to the Licensee Voneric Johnson (A1)