Complaint Investigation Report

Walnut House, Carmichael01/25/2024Licence 342700186

Census67
Date signed01/25/2024 04:54:07 PM
The inspector’s account

Allegation: Staff mishandled resident's medication.

Based on the file review of R1's January 2024 MAR, it revealed R1 is to take Eliquis 5mg tablet, twice a day. January 2024 MAR revealed the prescribed medication was signed for on January 20: AM and PM, January 21: AM and PM, January 22: AM and PM, January 23: AM and PM, January 24: AM and PM and January 25: AM. R1's MAR revealed Eliquis was given six (6) times during AM shift, starting January 20. R1's MAR revealed Eliquis was given five (5) times during PM shift, starting January 20.

Based on LPA and Regional Nurse medication audit, it revealed R1's AM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed four (4) tablets to be missing from the AM packet, instead of 6 as documented on R1's MAR. Based on LPA and Regional Nurse medication audit, it revealed R1's PM Eliquis 5mg packet's start date was labeled as January 20, 2024. Based on the medication count, LPA and Regional Nurse observed three (3) tablets to be missing from the PM packet, instead of 5 as documented on R1's MAR.

Based on the file review of R2's January 2024 MAR, it revealed R2 is to take Magox 400mg tablet, once a day. January 2024 MAR revealed the prescribed medication was signed for on January 21, January 22, January 23, January 24 and January 25. R2's MAR revealed Magox was given 5 times, starting January 21.

Based on LPA and Regional Nurse medication audit, it revealed R2's Magox 400 mg medication bottle's start date was labeled as January 21, 2024. Based on the medication count, LPA and Regional Nurse counted 96 pills present in the bottle out of 100 tablets, meaning 4 tablets to be missing, instead of 5 as documented on R2's MAR.

Please continue the report on LIC 9099-C2...

Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction