Complaint Investigation Report

496803698-12-31-2024-21-AS-BMOS-DCXNHB-20250115092827

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 1450 NEOTOMAS AVENUE, STE. 100

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

11/12/2024 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20241112160143

Facility staff did not dispense medication accurately resulting in resident's death

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. An anonymous Complainant has alleged that Resident R1 was administered morphine prescribed for another resident and that R1 died as a result. Based upon statements and documents reviewed the following determinations are made: R1 was prescribed morphine while on Hospice for pain following a fall on 11/2; R1 died on 11/9/2024; Facility Health and Wellness Director denies that R1 was given morphine prescribed for another resident and states R1 was administered morphine as directed that was prescribed for R1; The Death certificate for R1 gives the cause of death as Alzheimer's Disease with several other contributing factors, none of which result from medication or toxicity; no autopsy was done on R1. Although the allegation may be valid, based upon documents and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.