Complaint Investigation Report

Multiple relevant parties reported facility staff mismanaging residents’ medications. One relevant party reported that facility is missing medical records regarding medications for resident (R1), and relevant party identified medication errors for R1. Another relevant party reported that PRN medication is being used to sedate residents and facility is falsifying documentation to justify administering PRN medication. Report also indicated that facility frequently misses administering medications without reporting.

During a visit conducted on 6/04/2024, LPA Hood conducted a medication count for residents R1, R2, R3, and R4 comparing the resident’s Centrally Stored Medication Form (CSMF) with medications centrally stored for the residents. LPA did not observe any errors when comparing each resident’s CSMF with the medications counted.

Interview with staff members (S3 and S5) indicated that PRN medication for resident (R4) has gone missing or has been misplaced. Interview with staff member (S7) indicated that there was a medication error regarding insulin.

LPA received an Alta California Regional Center Special Incident Report (SIR) dated 4/29/2024 stating the following information: "On 4/29/2024, [staff member S13] noticed that another [staff member S12] administered 6 units of [medication] to [resident R3] based on [R3's] sliding scale instead of [medication] at bedtime on 4/28/2024." Interviews with Administrator indicated that S12 has not worked at the facility since incident.

Allegation: Residents are sustaining unexplained injuries