Complaint Investigation Report

MCM brought medication to room but was unable to locate medication mask in R1’s room to administer and unable to find replacement on med cart. MCM left room to request direction from nurse. Approximately 20 minutes later nurse returned to R1’s room finding R1 had called 911. R1 returned from hospital to facility same day. Documents obtained dated 6/1/2022 from Administrator, MCM could have informed R1 when leaving the room, what the plan was and could have offered the inhaler instead. The facility has since purchased an extra mask for the medication cart and conducted a mandatory Inservice training on 6/1/2022 for nursing team and all MCM’s regarding asthma, asthma triggers, asthma medication and interventions.The preponderance of evidence standard has been met: therefore, the above allegation is found to be Substantiated .

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided .