Complaint Investigation Report

Additionally, staff informed that occasionally there were glitches in the computer system, resulting in documented passes being erased upon printing the document. Staff informed that while there were some missing entries, the medication passes were correctly administered to the clients.

Four (4) outside sources were interviewed during the investigation. Outside sources corroborated the allegation, informing that the records they received from the facility included missing administration entries, inconsistent administration times, and unknown amounts given for as needed (PRN) medications. Outside sources stated that administration discrepancies made it difficult for practitioners to accurately assess client progress and adjust medications safely.

During an unannounced facility visit, LPA directly observed the MAR with blank, unexplained entries from a previous day. LPA inquired with a staff member who informed that the medications were administered correctly, but the staff had forgotten to click the button to confirm the administration time. A sample of client MAR records from April 2024 showed nine (9) blank entries among three (3) clients, without notation or explanation regarding the medication passes.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Program Manager Jennifer Melcher, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.