Complaint Investigation Report

On 10/03/2024, LPA Dolores interviewed 3 staff members. 3 out of 3 staff members state their procedures to follow-up with residents refills at least 7-10 days prior to the resident running out of medications.

Based on review of R1's medication administration record (MAR) and interview with S1, R1 did not receive his/her daily medication (medication #1) from 09/20/2024 - 09/26/2024 and daily medication (medication #3) on 09/26/2024. S1 stated that R1 was out of medication #1 and #3 and they did not receive his/her new medication until 09/27/2024.

On 10/03/2024, LPA Dolores reviewed R1's medication. Based on observation, it was found that R1 does not have a refill for bedtime medication (medication #2) and the last dose was given on 09/17/2024. Medication #2's instructions is for three times a day. LPA observed R1 has medication #2 for the morning and evening, but not for bedtime as the bedtime's medication pack is observed empty. The medication name, strength, quantity, and instructions for medication #2 are the same, but the medication packs are separated to morning, evening, and bedtime. Based on interview, staff (S4) stated that R1 doesn't like to come to the medication room during the evening times, even after they provide reminders. S4 states that because R1 doesn't take evening medication S4 administers the evening medication (medication #2) for bedtime, since R1 does not have anymore pills left in his/her bedtime medication pack.

The review of records shows that staff (S3) emailed R1's treatment team on 09/20/2024 (the day R1 ran out of medication #1) stating that R1 is out of 3 medications (#1, #2, and #3). On 09/26/2024, staff (S2) emailed R1's treatment team again stating that R1 is out of the 3 medications. A follow-up email was provided by R1's treatment team stating that R1's medication (#1 and #3) was sent to the pharmacy on Monday, 09/23/2024. Based on interview, S1 and S2 stated that the pharmacy refilled medication #1 and #3 on 09/23/2024 but the facility was not informed of the medication refill until 09/26/2024.

Based on interview, R1 has an appointment with his/her doctor on 10/05/2024 to refill medication #2 and to discuss another health related concern.

The Department has investigated the above allegation and the preponderance standard has been met, therefore, the above allegation is substantiated. Deficiencies were cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Program Director, Maria Canizales and a copy of the report and appeal rights were provided.