Complaint Investigation Report

Regarding the allegation that facility staff did not dispense resident's medication as prescribed, the investigation revealed the following: In interviews, the licensee and administrator stated that there was a medication administration error for C3 due to the fact that C3 was hospitalized several times in August.

Hospital discharge papers show that C3 was hospitalized from 8/3/21-8/10/21, 8/21/21-8/22/21, and 8/23/21-8/30/21.

Staff interviewed stated that there was a misunderstanding about which medications needed to be given to C3 upon discharge from the hospital on 8/10/21. The hospital discharge papers indicated that the next dose of evening medications were to be given by the facility "tonight." Per review of the MAR logs for 8/10/21, S1-S2 initialed for the medications Levertiracetam 750 mg and Clonidine HCL 0.1 mg but they were still in bubble pack. In interviews, S1-S2 stated that they did not dispense the medications on 8/10/21 but initialed their names by accident, thinking that medications were already given by the hospital. W1 stated that W1 observed these medication errors during a semi-annual visit and included the errors in the corrective action plan (CAP) report. The CAP indicated that there were three (3) medications errors: On 8/4/21, Levetiracetam 750 mg AM tablet was popped out of bubble pack even though C3 was still in the hospital, and there was no indication of why it was missing. On 8/10/21, evening medications of Levetiracetam 750 mg and Clonidine HCL 0.1 mg were still in the bubble pack and not dispensed despite hospital discharge papers indicating that evening medications were to be given by the facility that night. C1 stated that staff always give the medications on time, and C2-C3 could not be interviewed at this time.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6, Chapter 6, is being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights.