Complaint Investigation Report

Interviews with staff (S1 – S4) and outside sources (OS1 – OS3) revealed that R1 was prescribed an anti-psychotic medication for R1’s diagnosis of MND and the medication came in a 30-day supply. Interviews with staff (S1-S4) and outside sources (OS1, OS2) revealed that facility management became aware that R1’s medication had not been reordered from the pharmacy when R1’s family notified facility management during a care conference on 8/16/2021. Interviews with staff (S2, S3) revealed that the facility conducted an internal investigation which revealed that R1’s anti-psychotic medication supply ran out on 7/19/2021. Interviews with outside sources (OS1, OS2) revealed that R1’s medication should have been refilled on 7/1/2021, but the medication was never ordered. Interviews with staff (S2, S3) revealed that R1’s family was responsible for supplying R1’s medications, however, those staff members did state that it was ultimately the facility’s responsibility to ensure that all residents, including R1, had a large enough supply of medications to maintain proper administration. Despite R1’s medication not being ordered, interviews with staff (S1 – S3) revealed that R1’s medication administration record (MAR) did not show any missed doses. The Department was unable to obtain R1’s MAR for verification due to the facility no longer having those archived records. Medication technicians were interviewed by facility management and the Department, and those interviews revealed discrepancies regarding how R1 received the medication. Interviews with staff (S1, S3) revealed that sometime between 7/19/2021 and 8/19/2021, R1’s anti-psychotic medication was stored in a paper envelope. Interviews with facility staff (S1, S3) further revealed that medication technicians assumed that R1’s medication was being repackaged or reordered. As part of the internal medication audit conducted by facility management, it was determined that another resident (R2) had a discontinued prescription for the same anti-psychotic medication that was prescribed to R1 and that R2’s medication supply was missing approximately 9 pills. Interviews with S2 also revealed that a staff member (S6) admitted to giving R1 anti-psychotic medications from R2’s discontinued medication supply.

The Department has investigated the above-mentioned allegations and based on interviews, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated. The following deficiencies are cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. Executive Director provided POC documents during the visit and LPA Borunda was able to clear the deficiencies during the visit.

An exit interview was conducted with Executive Director Sheryl Johnston , whose signature below confirms receipt of a copy of this report, the Letter of Deficiencies Cleared, and the Licensee Appeal Rights (LIC9058 3/22).