Complaint Investigation Report

Allegation: Staff mismanaged resident's COVID-19 vaccine

Complaint alleged the facility mismanaged resident (R1)'s COVID-19 vaccine and accidentally provided R1 with two (2) differing vaccinations, which resulted in R1 having three (3) vaccinations total. On 08/04/2021, LPA Llopis conducted an initial on-site visit and spoke with the Administrator, three (3) staff and resident (R1). Administrator confirmed that the facility lost documentation of R1's first vaccination form. During initial visit, LPA reviewed resident records for R1 and found the following: R1 was provided their first vaccine dosage on 1/28/2021. R1's second dosage was provided on 2/21/2021. Vaccine cards indicate R1's first vaccination was Moderna, while the second vaccine was Pfizer. The third vaccine was provided on 03/14/2021.

Due to the above information, a deficiency is being cited and the allegation is being SUBSTANTIATED, meaning that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency cited can be found on LIC9099-D per California Code of Regulations, Title 22.

Exit interview conducted, copy of report and appeal rights provided.