Complaint Investigation Report

The prescription was written to change the strength of a medication that R1 was currently taking and the current medication was discontinued effective 10/12/23. According to the MAR, R1 did not receive any of the medication that was discontinued from 10/1/23 through 10/12/23. There are entries indicating the medication was not at the facility on 10/1/23, 10/8/23 and 10/12/23 but no explanation for the other dates. LPA Jensen also reviewed the Needs and Service Plan for R1 which was not signed or dated. As a result of the inconsistencies in the MAR and the incomplete Needs and Service Plan the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Allegation 2 - Staff did not address a resident's change in medical condition

LPA Jensen reviewed R1's physician report dated 7/13/23. The physician's report states R1 is able to independently transfer to and from bed, is able to dress and groom themselves and has no bladder or bowel impairment. This contradicts the Needs and Service Plan which states R1 requires hands on help with bathing, dressing and grooming. The Needs and Service Plan also states that the resident requires a one person assist with transfer and at times 2 person assist. It further states that R1 requires AM and PM incontinence care. All sections of the Needs and Service Plan state that the Care Team will monitor for changes in condition and conduct a reappraisal as appropriate. The Needs and Service Plan depicts a significantly higher level of need for care than provided for in the physician's report and as such a new physician report's should have been obtained. Based on the comparison between the LIC 602 (Physician's Report) and the Needs and Service Plan the allegation is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Allegation 3 - Staff did not properly report an incident involving a resident

LPA Jensen reviewed records showing R1 was hospitalized and being treated for a bacterial infection on or around 8/25/23. There was no evidence of an incident report being submitted to the Department for this occurrence and as such the allegation is SUBSTANTIATED.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report, an LIC 811 and appeal rights were provided.