Complaint Investigation Report

415601039-5-8-2024-14-AS-ACON-D7GLG9-20240724084422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SF COASTAL AC/SC , 851 TRAEGER AVE., SUITE 360

This is an official report of an unannounced visit/investigation of a complaint received in our office on

02/15/2024 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20240215114634

- Staff are not providing medication as prescribed

LPA Jeung reviewed file for client #1 and interviewed client #1. Staff involved in incident of 1/11/24 regarding client #1 is no longer employed. According to client, medication Seroquel (Quetiapine) was not given. Based on facility Progress Notes and Medication Administration Order Tracking, on 1/11/24, the medication was not maintained and not given. Client recounted that medication staff were unable to procure medication, so he requested to be taken to hospital, where he would be given the medication. This is also documented in the Progress Notes. Client said that he received medication and returned to facility without an overnight stay. It is documented that staff ordered medication on 1/9/24, but had not received it.

It cannot be determined that staff failed to administer medication as prescribed, as the electronic MAR and electronic Medication Administration Order Tracking--which reflects medications that were GIVEN--show inconsistent information for administration of Quetiapine in January 2024.

Based on information obtained, including interviews with resident and staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.