Complaint Investigation Report

The investigation reveals the following: Regarding " Staff mismanaged client's medication," it is alleged that C1’s medication was missing from the facility. During interviews with the administrator and staff member #1 stated that C1 take narcotics twice a day, but they took them four (4) times a day, which led to the missing medication. LPA reviewed the medication bottles and confirmed that one (1) bottle stated C1 should take the medication two (2) times a day, and another bottle stated C1 should take the medication every six (6) hours. The Administrator stated that they contacted the pharmacy and were told to give C1 the medication; however, the facility never obtained the client's physician’s orders. Staff #1 confirmed that the facility administered C1 Narcotics four (4) times a day. During the medication review.

Based on LPA observations, interviews, and file review, the preponderance-of-the-evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC9099D.

Exit Interview Conducted with Administrator/ Appeal Rights Provided / A Copy of the Report Issued.