Complaint Investigation Report

Staff 1 (S1) was interviewed and reported that the medication for Client 1 (C1) was mistakenly discarded. S1 stated that during the medication pass, S1 was simultaneously destroying discontinued medication, administering medication, and accepting newly delivered medication. S1 explained that they normally do not multitask while handling medications. S1 reported that a resident had recently requested a medication, and the pharmacy filled the order. S1 stated that while she was in the process of destroying the discontinued medication, the newly delivered medication was mistakenly included and destroyed in error. When the resident later asked for the medication, S1 was unable to locate it and realized it had been destroyed. S1 further reported that when the facility contacted the prescribing physician to request a replacement, the

Physician authorized the refill the medication and was delivered the same day.

LPA Domingo conducted an observation of the medication storage area and reviewed the facility’s medication charts. The medication area was organized and free of clutter. Each medication basket was clearly labeled with the corresponding resident’s name. Medications stored in each basket matched the residents’ current medication lists, and no discrepancies or missing medications were noted at the time of the visit.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation 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 Cynthia Rodriguez-Reina Administrator to whom a copy of this report, the Licensee/Appeal Rights (LIC9058 03/22) were provided.