Complaint Investigation Report

Review of R1's file did not indicate any communication to R1's Primary Care Physician or pharmacy regarding refills. Review of R1’s Electronic Medication Authorization Record (EMAR) and Narcotic Log for February and March 2024 revealed that R1 received their last dose of Ativan on 3/2/2024. Review of R1's file indicated that the facility notified R1's Primary Care Physician and pharmacy. Per documentation, the facility was actively attempting to have medication refilled but were unsuccessful. Complaint alleged that during a visit on 3/6/2024, the resident’s behavior was “off.” When staff were questioned about resident’s medication, they indicated that the resident had been out of the medication for a week. Staff interviews conducted indicated that the facility protocol is to contact the Physician and pharmacy at least 7 days prior to a medication running out. Based on document review and interviews conducted, this allegation is Substantiated.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An Immediate Civil Penalty in the total amount of $250 is being assessed for a repeat violation of Regulation 87465(a)(4) more than once in a 12 month period. (See LIC421FC)**

Exit interview conducted. Copy of report, LIC809D, LIC421FC (Civil Penalty), LIC811 (Confidential Names), and Appeal Rights, discussed and provided to Executive Director/Administrator, and Health and Wellness Director. Signature on form confirms receipt of documents.