Complaint Investigation Report

Based on a review of the facility forms and documents, it was learned that this facility employed a digital version of the Medication Administration Record (MAR) for all facility residents at this time. It was learned that all facility residents had their medications centrally stored and did not have immediate control of their medications at this time. A brief interview was also conducted with the facility designated Administrator, Monica Plowden, in regards to the maintenance, oversight, and auditing of this system.

Based on this interview, it was learned that facility staff were responsible to handle, dispense, and notate all of their actions within this program. It was also learned that this program required each individual staff person to log in when it came time for them to dispense the medications as prescribed.

It was learned that if a facility resident refused or did not take their prescribed medications in a timely manner, the present facility staff person would use a drop down menu, within the application, to notate that the medications were not given and should include additional notes as to the specific reason. It was observed by this LPA from the monthly medication administration records (MARs), dated from 09/16/2024 to 11/14/2024 for all (6) residents, revealed multiple times and dates where the medications were not property dispensed, not properly documented, and not properly followed up with Notes inputted within this application.

Based on interviews conducted during the course of this investigation, it was learned that there wasn't a cohesion within the core group of facility caregivers, which there were (3) main facility staff persons at this time. It was learned that on at least (1) occasion, the oncoming staff came on and discovered that the scheduled staff for the previous shift had left the facility without notification to the oncoming shift or the facility administrative team. It was learned that the facility residents had been left alone, without any facility staff care and supervision, for an unknown amount of time before the oncoming shift finally arrived to take over.

It was learned that there were notifications, in the form of phone calls and text messages, that were exchanged with the facility designated Administrator in regards to this incident.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated representative at this time.