Complaint Investigation Report

The investigation reveals the following: Regarding "Medication error" it is alleged that the facility had a medication error on 4/13/22. Interviews with S1, S2 and administrator confirmed medication error occurred due to staff not following facility protocol. Administrator, S1 and S2 stated that training was given by Regional center on 4/22/22. Administrator stated another training is schedule by facility nurse to make sure they stay in compliance. LPA reviewed all residents’ medications and observed C2 medication (Docusate Sodium PM) was not in bubble pack but staff did not sign off on Medication Administration Record (MAR) as given.

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, is being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to the S2 along with the Appeals Rights.