Complaint Investigation Report

On 10/01/25, LPA retrieved a copy of R1’s Morphine Record (08/04/25), Physician’s Reports (R2 – R6), Updated Training Record (S1) and interviewed Witnesses #1 - #2. Note: LPA left a message/voicemail to interview Witness #5 - # 6, #8 (09/17/25, 09/29/25), and Witness #9 - #10 (09/29/25).

Allegation: Staff not qualified to give medication.

Regarding the allegation, “Staff not qualified to give medication,” it is being alleged that Staff #1 was not qualified to administer R1’s medication. Record review of personnel policies revealed that each employee is required to have continuous training and applicable certificates in hospice care and proper handling of medication and required documentation. Medications’ policy and procedure revealed that two hours of hands-on-shadowing training will be provided prior to assisting with the self-administration of medication. Record review of staff training revealed S1 has zero (0) medication training in 2024 and three hours of medication training in 2025. Record review of hospice medication administration record revealed S1 administered R1’s medication on 08/05/25 10:30 AM.

Regarding the allegation, “Staff not qualified to give medication,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. Health and Safety Code, Title 22, Division (6) and Chapter (03.2) are being cited on the attached LIC 9099D.

An exit interview was conducted, plans of correction developed, and a copy of this report with appeal rights were provided to the Area Manager Irene Formentera.