Complaint Investigation Report

Additional evidence was gathered during the investigation process and witness interviews conducted.

Regarding the allegation that Residents medication is being mishandled, the following has been concluded: Based on interviews conducted and a review of the Medication Administration Records (MAR) provided by the facility, it was determined that all medications dispensed had a corresponding prescription/physician order as required by Title 22 Regulations. Title 22 regulations do not require pre-approval from or notification to the attorney-in-fact prior to dispensation as long as physician orders are on file. However, it was also determined during the investigation that a request to discontinue the administration of Depakote was made by the resident's attorney-in-fact and implemented effective January 25, 2022 per the MAR and physician order reviewed. Later blood tests performed on March 9, 2022 after R1 was hospitalized at Saddleback Hospital show blood levels for Valproic Acid (Depakote) to be below 3ug/ML which was determined to be consistent with the medication being discontinued per the request expressed to the facility. Pharmacy invoices provided also confirm that no additional billing for that specific medication is present after the discontinuation.

As a result, the allegation is found to be Unsubstantiated, meaning t hat although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.