Complaint Investigation Report

During a visit conducted on 10/05/2023, LPA conducted a medication count for resident R1, comparing the resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPA observed one (1) medication for R1 that was off count in relation to what was documented. Medication that was off count was over the amount documented. There were no documented refusals for R1’s medication when reviewing R1's medication Admin History. LPA reviewed Shift Reports and observed that it was noted under NOC shift notes for 9/22/2023 that new medications for R1 were delivered and ready to use at 4:00 AM on 9/22/2023 despite R1's medication not being documented as given until 9/23/2023. Interviews conducted indicated that the documented date for when medications were received was incorrect.

On 10/06/2023, ED informed LPA that they began conducting an internal investigation and discovered that bubble pack for R1's medication had tape on the back of the bubble pack, indicating that pills had been placed in the pack after the seal had been broken. ED also discovered a bottle of the same medication for resident (R2) that was supposed to be destroyed underneath a staff member's (S2's) desk with tin foil inside the bottle. ED stated that there was no documentation indicating that R2's medication had been destroyed or removed from the medication room.

During a visit conducted on 10/05/2023, LPA conducted a tour of the facility to inspect facility's Personal Protective Equipment (PPE). LPA observed facility had a sufficient supply of N-95 respirators, surgical masks, gloves, face shields, gowns, and hand sanitizer. LPA observed one (1) resident on isolation due to COVID-19 exposure and COVID-19 symptoms (resident refused to test). LPA observed PPE cart outside of resident's apartment and observed cart did not have N-95 respirators. LPA also did not observe PPE instructions posted outside of resident's apartment. LPA interviewed representative from Sacramento County Public Health. They stated that they still advise staff working at long-term care facilities to use full PPE when caring for residents who are in isolation due to COVID-19 per PIN 23-13-ASC. PIN 23-13-ASC states the following: "Important! Facility staff must wear the appropriate PPE (i.e., N95 respirator, and gloves) pursuant to facility specific regulations. Licensees are encouraged to have signage in the facility on proper PPE donning and doffing."