Complaint Investigation Report

Based on statements and documents, on 3/7/22 three (3) of four (4) residents had 12:00 PM medications delayed until 1:20 PM when staff assumed S1 was to do medication passes yet S1 was not present at the facility at 12:00 PM. Other staff working with clients R1, R2, and R3 did not identify and facilitate that the clients to whom they were assigned received their scheduled medications. Based on medication orders a medication administration record (MAR) identified the resident need for medication at 12:00 PM

Client physicians were contacted, medication times were adjusted and clients suffered no ill effects due to the delay.

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 Carly . Copy of this report and appeal rights provided.