Complaint Investigation Report

Allegation: Staff mismanaged client's medication. On 08/24/2023, it was discovered that C1’s individual bubble pack / Individual packet medication is missing for the evening 08/25/2023. Staff found the missing bubble pack and it appears that the bubble pack / Individual packet date was altered, was whiteout and handwritten the date on it.

At the time of today’s visit interviewed Administrator stated, staff informed the Administrator that the 8/23/23 packet had separated from the sheet and was missing, so they administered medication from the packet dated 8/25/23 to ensure that C1 would not miss a prescribed dosage. Interviewed administrator and staff stated that staff began to look for the missing packet right away, knowing that the medication was there earlier. As the ELARC representative was leaving the facility, staff found the missing packet. The packet had fallen into the bottom of the drawer in which the medication is stored. The representative informed the staff to just email a picture of the packet to her. The representative also informed staff that the packet should have the correct date on it. Staff had interpreted that to mean change the date to represent the date medication is to be given. Therefore, staff used white out to put the correct date on the medication packet. S1 whited out 8/23/23 and used a pen to write 8/25/23 on the single packet of medication.

Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted with Horace Hall. A copy of the report and appeal rights were issued.