Complaint Investigation Report

The staff contacted C1’s doctor on 1/17/2024 and left a message with the doctor due to the doctor being out of the office. The facility staff did not administer the new medication until the staff received communication from the doctor on 1/23/2024.The facility staff did not reveal any additional measures or contacts, such as contacting a pharmacy and or a nurse hotline, that were made to verify if the new medication would interfere with C1’s current medication.

Interviews with the clients revealed that the clients did not have any concerns about their medications being administered.

A document review of email communication between C1’s family member and the Administrator revealed that a new medication was dropped off at the facility for C1 on 1/17/2024. The facility staff informed C1’s family member that the medication would not be administered until the staff spoke to C1’s doctor’s office. A document review of C1’s medication record (MAR) revealed that one (1) of C1’s medication was ordered to be administered once daily or every other day for maintenance. In the month of December 2023, this medication was only administered eight (8) days out of the thirty-one (31) calendar days. Additionally, C1’s new medication that was received on 1/17/2024 was not administered the until 1/23/2024.

Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099), LIC9099D, and LIC811 were discussed and provided Administrator Ruth Anguiano, along with a copy of the appeal rights.