Complaint Investigation Report

The LPA requested the following records for R1 and R2: LIC 602 Physicians Reports, Appraisal Needs and Services Plan (ANS), Hospice Admit records, Hospice Agency Name and phone numbers, Hospice Care Plans, Medication Administration Records (MAR) for 10/2022-11/2022, Centrally Stored Medication and Destruction Records (CSMDR), Incident Reports, Death Reports, Death Certificates, Call pendant logs for 10/2022-11/2022, Staff and Hospice Notes 09/2022-11/2022, Resident Roster for 11/2022 and 01/2023 with telephone numbers, Staff and Hospice notes for 09/2022-11/2022, Staff 1 (S1) hire date at the facility and hire date of last promotion, Staff Roster with telephone numbers for 11/2022 and 01/2023. The LPA informed Administrator that the complaint was referred to the Community Care Licensing (CCL) Investigation Branch (IB). On 03/23/2023 Investigator Munoz contacted the Reporting Party (RP); on 03/24/2023, from approximately 1:00pm to 1:15pm, contacted facility staff to schedule in-person interviews; on 03/27/2023, from approximately 9:30am to 10:10am, conducted interviews with staff; on 04/05/2023, at approximately 2:30pm, with RP; on 04/06/2023, from approximately 4:00pm to 4:05pm, left message for S1 and interviewed Administrator; on 04/11/2023, at approximately 1:40pm, left message for S1; and on 04/14/2023, at approximately 11:39am, interviewed S1. In addition, the investigator reviewed Wilshire Hospice Agency records related to R1 and R2, and facility file documents relevant to the investigation.

The Wilshire Hospice Agency records revealed that on 07/15/2022, R1 was admitted in hospice care and given a life expectancy of six months or less for hypertensive heart with Chronic Kidney Disease. On that same day, R1 was prescribed morphine, .25ml for mild pain, 0.5ml for moderate and 1ml for severe pain to be given every hour or as needed. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. There were no indications R1’s medications were not given as prescribed.

On 12/30/2021, R2 was admitted in hospice care and given a life expectancy of six months or less if illness runs normal course. On this same day, R2 was prescribed morphine to be taken every hour or as needed for pain. R2 was prescribed .25ml for mild pain, 0.5ml for moderate and 1.ml for severe pain. The death certificate listed the cause of death as Acute Cardiopulmonary Arrest, Congestive Heart Failure, Hypertensive Heart Disease. There were no indications R2’s medications were not given as prescribed.