Complaint Investigation Report

Regarding the allegation that staff do not administer resident’s medications as prescribed, according to the reporting party, on 1/9/2024, staff waited until 4:30pm to provide Benzodiazepine Onfi to R1 at 3pm as prescribed by R1's physician which caused R1 to have a seizure.

During the investigation LPA interviewed the administrator, reviewed R1’s medication list and medication orders. According to the administrator, staff called administrator around 4:20pm indicating R1 is having a seizure and administrator instructed staff to not provide R1 his/her seizure medication until R1 was stable. Based on the R1’s seizure log reviewed, on 1/9/2024, R1 did not have a seizure until 4:20pm. According to the administrator, she is unsure why R1 didn’t receive his/her medication at 3pm as prescribed. Based on R1’s physician's order, R1 is to receive Onfi three times a day; 7:30am, one at 3pm, and one at 9pm. Based on interviews conducted and information collected, staff did not administer resident's medication as prescribed by the physician.

Regarding the allegation, staff are not adequately trained to meet resident’s needs, according to the reporting party, R1 was admitted to the facility back in December of 2022, however the facility has not received any trainings on how to support R1’s seizure and when to give R1 medical attention.

During the investigation, LPA interviewed the administrator and requested training documentation. According to the administrator, she has not provided formal training to the staff regarding caring for R1. In addition, the administrator was unable to locate or provide LPA any training records regarding caring for R1 that may have been conducted by the previous administrator.

Therefore, based on the records reviewed, interviews conducted, and information collected, the allegations facility is operating out of staffing ratio, staff do not administer resident's medication as prescribed, and staff are not adequately trained to meet resident's needs is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Caregiver, Carmelita De Castro and a copy is provided with appeal rights.