Complaint Investigation Report

During this investigation, an additional medication issue was found. On 10/11/24, R2's family was notified of two medications that are due for refills. Due to the short notice weekend alert and some pharmacy related issues, R2 missed a dose of two medications. Furthermore, family provided and the staff accepted medications into the med room that were not in prescription bottles not logged into centrally stored medication. All medications for R2 have since been filled and R2 was unharmed. Centrally stored medication records for the two missed medications for R2 did not record the number of refills available for the medications.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Carol Pickard . Copy of this report and appeal rights provided.