Complaint Investigation Report

During the interview of a staff member (S1), it was mentioned that on 01/07/2022, about 2:30, S1 got here to the facility to check on the morning staff since they are fairly new. S1 saw that R1s F1 was upset and demanding a recount of the meds. S1 found that it was two days more of the bedtimes. S1 thought that was 2-3 extra pills over the medications. The rest of the meds were okay and correlated with the MAR. S1 apologized for the meds and said it was the NOC shift that packed the meds. When F1 left, they took the right medication home.

According to the daily logs provided by the facility, an entry on 1/07/2022 at 3:55pm, noted that staff got a call from Momentum that F1 went to talk to them about R1s medication. Staff spoke with Nurse from doctor’s office to confirm if the prescription order of M1 sent from Momentum was in steps 1-3 because staff followed the instruction from the paperwork and also informed the nurse that Momentum did not update pharmacy regarding the prescription order sent to facility as pharmacy still follow R1s old med list. Nurse apologized and said they will send the prescription order to pharmacy after he/she drop the call with staff and also will tell F1 to give R1 100mg on date 7th and 200mg starting date 8th and bring the rest back to facility.

Based on the Medication Administration Records (MAR) obtained, on the dates of 1/6-7/2022, there were no logs of medication being given to resident.

Based on interviews and records review and information collected, the above allegations are 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 and a copy of this report and appeal rights are provided.