Complaint Investigation Report

Additionally, there a multiple days and shifts (both AM and PM) where no staff are scheduled for 1:1 for either resident. R1 is approved for 15 hours of 1:1 supervision during waking hours due to R1’s disruptive behavior (IPP dated 9/23/19) and R2 is approved for up to 16 hours of 1:1 supervision during waking hours due to “severe behaviors” (IPP dated 10/15/19). Therefore, based on interviews and record review, the allegation “Facility is inadequately staffed.” Is SUBSTANTIATED.

Regarding allegation " Facility staff gave resident the wrong prescribed medication, causing an allergic reaction": LPA Colvin conducted interviews with staff as well as reviewed facility records for R1. LPA Colvin observed a Special Incident Report (SIR) dated 11/20/20, wherein it was reported that a staff member (S1) accidentally administered the wrong medication to R1 during AM medication pass. According to the SIR, one of the medications accidentally administered to R1 (Olanzapine) is a medication that R1 is allergic to. R1’s responsible parties were notified and 911 was called and R1 was admitted to the ER for observation. The SIR additionally stated that prior to calling 911, staff observed R1 to be “off his baseline” and R1’s responsible parties stated that in the past, when R1 has taken this medication R1 has become delirious and unable to walk. Additional staff interviews conducted by LPA Colvin revealed that R1 was “extremely groggy” and “super sleepy” and a staff member was sent to the ER to watch R1. Therefore, due to record review and interviews conducted, the allegation “Facility staff gave resident the wrong prescribed medication, causing an allergic reaction.” Is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to House Manager Paulina Corona during the exit interview.