Complaint Investigation Report

Also, through the video footage, LPA observed the facility did not properly store medications in a medication cart/cabinet, and it was kept unlocked and accessible to clients in care.

The incident occurred on 1/24/2024 approximately 2:25 AM, when C1 was able to gain access to the medication room that was left unlocked. Once C1 gained access to the room, C1 was able to ingest medications such as: Keppra, Depakote, and Gabapentin that resulted C1 to be transferred to ICU at Los Robles Hospital.

During today’s visit, LPAs Ngo-Castaneda and Panushkina conducted an interview with COO and DON and both parties also confirmed that during the video footage, dated on 01/24/24, they observed that S2 left the shift without locking the medication cabinet and or checking to see if the sliding door in a Medication Room was kept locked.

LPAs were also provided with a copy of a video footage and confirmed the medication cabinet and the sliding door to the Medication Room were not locked and remained accessible to clients in care. At 12:20pm, LPA Panushkina contacted S2 and was informed that the facility had no policy of locking the medication cabinet until the incident occurred on 01/24/24. S2 also informed LPA that during the shift changes no one was told to confirm if the sliding door to the medication room was kept locked. In addition, at 12:30pm, LPA contacted S3 and S3 confirmed the fact that the facility had no policy of locking the medication cart/cabinet and or checking if the sliding door is locked during their shift changes. However, LPAs conducted review of Medication Policy and observed that “All medication shall be stored in locking cabinets or carts.”

This is an immediate health and safety risk to clients in care. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED.

Appeal Rights explained. Exit Interview conducted.