Complaint Investigation Report
Following is a summary of the investigation findings:
Regarding allegation, “Staff did not notify resident’s responsible party of an incident” – it was alleged that Resident #1 (R1) sustained a fall at the facility on June 22, 2023, a week after admission and the responsible party was not informed. Staff interviewed revealed that R1 was admitted on 06/13/2023 and did sustain two (2) falls on or about 06/22/2023 and another in 08/23/2023. Staff interviews and records reviewed confirmed that the 06/22/2023 fall was not reported to the responsible person or the department. Based on the above information gathered, there is sufficient evidence to support the allegation of “Staff did not notify resident’s responsible party of an incident”. Therefore, the allegation is deemed SUBSTANTIATED at this time.
Regarding allegation, “Staff did not communicate with resident's family regarding increase in medication” – Information was received that facility staff requested a medication change from R1’s doctor without obtaining consent from R1’s responsible party. Records reviewed and interviews conducted with staff on 09/13/2023 revealed that between 6/24/2023-8/24/2023, R1’s was exhibiting behavioral issues which was reported to the doctor and therefore the seroquel medication was increased. Staff interviewed and records reviewed confirmed that R1’s seroquel medication was increased from 50mg to 75mg then to 100mg. Interview with staff revealed that R1’s change in condition since move-in and medication changes were not communicated to R1’s responsible person. Based on the above information gathered, there is sufficient evidence to support allegation “Staff did not communicate with resident's family regarding increase in medication”. Therefore, the allegation is deemed SUBSTANTIATED at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies was cited (refer to LIC 809-D):
Exit interview conducted. A copy of the report and appeal rights provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction