Complaint Investigation Report

The complainant concern was that the client in question was able to gain access to medications that should have been stored and inaccessible. 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 (made on 02/08/24), LPAs Ngo-Castaneda and Panushkina were informed by COO and DON that during the video footage they observed S2 leaving the shift without locking the medication cabinet and or checking to see if the sliding door in the Medication Room was kept locked. LPAs were also provided with a copy of a video footage from 01/24/24 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.” Lastly, all staff interviewed had no idea how and who left the sliding door open. Moreover, interview with S1 revealed that in between 9:30AM-10:00AM Staff #1 (S1) found C1 in their bedroom unconscious. Facility staff immediately contacted 911 and C1 was admitted to ICU at Los Robles Hospital. Medical Records (received on 1/26/24) confirmed that C1 was diagnosed with drug overdose, with no signs of acute distress, hematoma and or other injuries.

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. This is a violation that resulted in injury to resident in care. A $500 civil penalty shall be issued today however, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1548(f)(1)(a).

Deficiency cited on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.