Complaint Investigation Report

Per review of R1's medical records the facility received a fax from R1's current physician requesting the medication of Oxybutynin to be tapered off and then discontinued, the fax was received on 07/19/2023. Per review of medication administration records (MAR) Oxybutynin was tapered off and eventually discontinued in August of 2023, review of December 2023 MAR the medication is refilled by R1's former physician and continued to be given to R1 until August 14th 2024.

Based on interview with Health Services Director Marties Meneses she started at the community around August 2023. Health Services Director stated the order was followed but in December 2023, someone on her staff found the original order of Oxybutynin from R1's former physician dated 3/16/2023. Heath Services Director stated that once it was brought to her attention that an order was received on 07/19/2023 by R1's current physician then the MAR was updated. Health Services Director stated the order from 07/19/2023 was filed by previous Health Services Director and was not located until August 2024. Per interview with Health Services Director the issue was not reported to the Department.

It was alleged on or around December 2023 R1's neurologist prescribed Sertraline. Per interview with Health Services Director it was confirmed the facility received a prescription for Sertraline on 12/29/2023. Per review of the MAR Sertraline was not given to R1 until 2/10/2024. Health Services Director was unable to provide information as to why the medication was not provided from 12/29/2023 to 02/09/2024 as she stated it was added to medication list by pharmacy. LPA Mendivil's review of MAR from December 2023 to February 2024 do not mention Sertraline or any brand name for Sertraline until 2/10/2024.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegations

facility did not provide medications as prescribed and facility did not meet reporting requirements are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.