Complaint Investigation Report

Department review of R1’s Physician’s Report shows diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, mild cognitive impairment (MCI), and dementia. R1 was admitted to the facility on March 29, 2025, following transfer from a skilled nursing facility, and required full assistance with Activities of Daily Living (ADLs).

Departments review of R1’s Medication Administration Record (MAR) shows clonidine patches were documented as applied per physician orders on 3/31/2025, 4/7/2025, and 4/14/2025. Further record review reveal that on April 19, 2025, staff observed a change of condition during the dinner hour. At 8:46 PM, staff contacted emergency services, and R1 was transported to the hospital.

Department Hospital records review dated April 19, 2025, confirm that two Clonidine patches were present and removed during R1’s admission: one patch dated 3/28/2025 located on right side of the neck and one undated patch located on the right shoulder. Department interviews with staff revealed they were unable to provide documentation explaining how the duplicate patches occurred. Under Title 22, the licensee is responsible for ensuring medications are administered as prescribed and for maintaining records and oversight to prevent medication errors. The presence of two Clonidine patches is inconsistent with physician orders and MAR documentation and demonstrates a failure to properly assist with medication administration and monitoring.

The Department has investigated the above mentioned allegation, and based on interviews and records review, the preponderance of evidence has been met. Therefore, this allegation is deemed substantiated . The following deficiency for failure to ensure proper medication assistance and oversight is cited per California Code of Regulations, Title 22, and is noted on the attached LIC 9099D page.

An exit interview was conducted with Executive Director Angela [Last Name], whose signature below confirms receipt of this report and the Licensee Appeal Rights (LIC 9058 03/22).