Complaint Investigation Report

Interviews and a review of records showed that Resident 2 (R2) was prescribed a Fentanyl 50 mcg/hour transdermal patch, with instructions to apply one patch topically every 72 hours. Records indicate that the patch was applied on 05/07/2024 at 8:00 a.m., and again on 05/10/2024 , at 8:00 a.m. R2 was admitted to a local hospital on 05/12/2024, and returned to the facility at approximately 9:45 p.m. that same day. There is no documentation showing that the patch was replaced on 05/13/2024, as would have been scheduled based on the prescribed 72-hour cycle. However, records do indicate that the patch was replaced on 05/16, 05/19 and 05/22 each at 8:00 a.m. Staff interviews did not confirm whether the patch was replaced on 05/13/2024. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation above. Therefore, the allegation "Staff did not provide medical attention to resident in a timely manner" has been deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.