Complaint Investigation Report

Interview with ED indicated that an injectable medication for R1 was received by the facility on 9/12/2024 and S1 brought the package in which medication was stored directly to R1 and placed contents in R1's refrigerator. ED stated that it was believed that R1 self-administered the injectable medication. Interview with S1 indicated that they received a package for R1 while working at the front desk and observed that package needed to be refrigerated immediately. S1 stated that they noticed the name on the package and took the package to R1's room right away. S1 stated that they opened the package with R1 and had R1 stored contents of package in their refrigerator.

LPAs received a Special Incident Report (SIR) regarding the incident date 9/19/2024. SIR states "Resident had medication delivered on 9/12/2024. Medication was not located in the community. On 9/19/2024 it was discovered that an employee had taken the medication directly to the resident, who then self-administered. Resident observed and monitored, determined to be ok."

LPAs reviewed R1's Physician's Report LIC 602A dated 3/18/2024, which states R1 is not able to administer own prescription medications but is able to administer own injections with assistance and observation. LIC 602A also states that R1 is not able to store own medications.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.