Complaint Investigation Report

(Continued from LIC9099 p.1) Review of facility records revealed documentation from the facility requesting families to send additional toilet paper due to their resident running low or going through it quickly. LPA spoke with a staff member who contacted a family to bring additional toilet paper to confirm if the request was done to accommodate the rule, or if it was due to resident preference of brand. The staff member stated that they contacted the family to provide more toilet paper due to the rule of 2 rolls per week. Review of the Residence and Care Agreement revealed no documented policy informing families and residents of the 2 rolls per week rule. The agreement offers that the facility will provide, for a fee, certain personal care supplies if a resident is unable or chooses not to purchase them for themselves. However, the item of toilet paper was not found as a purchasable item from the facility. An additional document referenced in the Residence and Care Agreement pertinent to this procedure was not able to be produced by the facility.

Three outside sources were contacted regarding the allegation. One outside source was not aware of any issues surrounding toilet paper at the facility. A second outside source was not able to speak to the allegation due to lack of consent from the resident in question. A third outside source confirmed the facility policy regarding 2 toilet paper rolls per week and advised they were not made aware of the rule prior to their resident moving into the facility.

Regarding the allegation, "Licensee did not administer medication as prescribed", the accuracy of R1's medication administration by the facility was brought into question, and that the facility cancelled an eye drop prescription for R1 outside of the doctor's order. Staff members interviewed did not have knowledge of any medication errors for R1, however, the Medication Administration Record during the timeframe of the complaint showed that a PM medication administration was not given on 04/11/2024. No records were found to explain the missing administration, such as documentation error or resident refusal. Review of facility records revealed that the facility received an order from R1's doctor to discontinue an eye drop medication on 04/17/23. Additional records showed that the existing supply for the medication was discarded due to being expired. No evidence was found to support that R1's prescription was discontinued by the facility outside of the physician's order, or that a medication error existed with the eye drops. An outside source familiar with the issue was not able to speak to the allegation due to lack of consent from the resident. R1 was not able to be interviewed due to no longer living at the facility.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided