Complaint Investigation Report

The staff code indicates which nurse administered the medication and the reason for entry. For 07/03/23, there was an X along with the code 09. According to the MAR legend, code 09 means "other/see nurse notes". LPA Valerio reviewed five out of five pages of nurse notes for July of 2023. LPA observed a note missing for 07/03/23 at 16:00, which does not show the reason for the missing entry. Due to this error, a person cannot determine if the resident did or did not receive the medication.

R5's MAR dated July of 2023 was reviewed. Per R5's admission agreement, R5 moved into the facility on 06/30/2023. LPA Valerio observed all regularly scheduled medications to be missing a signature indicating medications were provided to the resident. The MAR showed the resident started receiving medications on 07/04/23.

According to an interview with ED Alex, R5 moved in on 06/30/2023 and had a paper MAR until medications were interfaced by the pharmacist. If R5 moved into the facility on 06/30/23, R5 should have been given medications. According to ED Alex, R5 was not in the community from 06/30/2023 until 07/04/2023.

Based on records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was left at the facility