Complaint Investigation Report

Per review of records, clients have received the PRN medication for not going to sleep and/or repeated requests. Medication review of records showed C2 missed prescribed medications, two (2), on 12/7, 12/12, and 12/15, in 2023; Reason written for missed dosage of medications, the facility didn't have it/not filled and on-site. PRN medications reviewed are prescribed for agitation. Regional Manager Paula stated to the LPA that PRN's are to be provided to clients as last resort not right away, and agreed the documentation "PRN Criteria" is confusing, in when the agitation medication is to be provided. LPA reviewed findings of the complaint with Paula Siffit, and showed facility documents that support a violation(s) has occurred.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of " Medications are not administered per Dr's Order" , has been substantiated.

Due to the substantiation of the allegation, a citation will be cited today, Health Related Services(b)(5)(A)(B) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met: There is a written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section, dosage instructions. Once ordered by the physician the medication is given according to the physician's directions, see LIC9099D.

T he preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed

Exit interview conducted with RM Paula Sifflet.