Complaint Investigation Report

R1 only received one dosage of her Prednisone 20 MG tablet medication since she was hospitalized on May 16, 2025, so there should be four remaining tablets for R1’s Prednisone 20 MG tablet medication. However, per the facility’s medication release form dated May 20, 2025, which was provided to R1’s family, there were only two tablets remaining for R1’s Prednisone 20 MG tablet medication. Therefore, a medication occurred on May 16, 2025, in which R1 received double her dosage for her Prednisone 20 MG tablet medication. Furthermore, LPA reviewed an Internal Occurrence Report from the facility dated May 2, 2025. The Internal Occurrence Report describes how a facility staff mismanaged R1’s Ropinirole 3 MG tablet medication by giving R1 triple her prescribed dosage. Five out of six staff interviews conducted with staff that assist residents with medication confirmed a medication error occurred on May 2, 2025, in which R1 received triple her prescribed dosage for her Ropinirole 3 MG tablet medication. The facility’s Licensed Vocational Nurse (LVN) who was on duty on May 2, 2025, then assessed R1 after the medication error and did not note any adverse reactions. Facility staff then contacted R1’s Primary Care Physician (PCP) who advised the facility that R1 could remain in the community since R1 did not have any adverse reactions. Facility staff then continued to monitor R1s condition by monitoring R1’s blood pressure, heart rate, respiration, and temperature. R1’s family was also informed of the medication error.

Based on interviews conducted and the evidence gathered, the Department obtained sufficient evidence to substantiate the allegation that staff mismanaged residents’ medication. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED . See LIC9099D for the deficiency cited per Title 22 Division 6 of the California Code of Regulations.

The investigation revealed the following: It was alleged that staff did not assist residents with care in a timely manner. LPA reviewed the call button response times dated March 8, 2025, to May 16, 2025, for R1. Per the call button response times, LPA observed that there were numerous occasions in which R1 had to wait extended periods of time to be assisted by facility staff after she pressed her call button. CONTINUED ON LIC9099-C