Complaint Investigation Report

The admission agreement states that “If we determine that you need a different level of care than that which you are currently receiving , we will provide you and your responsible party, if applicable, with a written notice of the reasons for and the effective date, of the change." And “if you begin receiving a different level of care, the rate for the new level of care shall be charged immediately. We will give you written notice of a level of care rate increase within two (2) business days after providing services at the new level of care.” R1 was assessed by the facility to have needs beyond the care plan R1 was receiving. R1 was receiving enhanced care for two months prior to being charged for the additional care. When the facility determined that the rate would be changed to the higher level of care the facility did communicate with the responsible parties about the care provided and R1’s needs, however, they did not provide written notice to the responsible parties. This is in violation of the admission agreement and this allegation is Substantiated.

The allegation that the facility staff mismanaged resident’s medication was the result of an incident that resulted in R1 receiving a double dose of a supplement. The error occurred when R1 was admitted to a hospice agency for care. The facility had a supply of the supplement on hand for R1 and the hospice agency sent a supply of the supplement to the facility. Staff 1 (S1) gave doses of the supplement to R1 from both supplies resulting in R1 receiving a double dose of the supplement. S2 discovered the error and reported the error. The facility notified R1’s medial provider and R1’s responsible party. R1 was monitored closely and no ill effects were noted. Interviews revealed that the medication handling procedures broke down in two places contributing to the medication error. S3 accepted the medication and placed excess medication into the medication cart instead of the location for excess medication, and S1 did not check the Electronic Medication Administration Record when preparing to give R1 their medication. This allegation is Substantiated

A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D.

This report was discussed with Lindsay Hahn, Resident Services Coordinator. A copy along with Licensee Rights (01/2016) was emailed to facility staff at the conclusion of the visit. An electronic response confirms the receipt of these documents.