Complaint Investigation Report

Yet varying statements were provided from staff whether R1's responsible party was notified of R1's regular refusal of medications. A review of R1’s Electronic Medication Administration Record (eMAR) for the months of April-August 2021 indicated that R1 regularly refused to take medications. Staff interviews revealed that R1 was adamant in their refusal despite the different interventions staff attempted in assisting R1 with the self-administration of medication. As a result, staff said that R1’s medications were discontinued in August 2021. The LPA reviewed an order signed by R1’s physician on 8/28/2021, indicating that R1’s medications were discontinued, with the note pt refusing anyway. Progress notes did not indicate that R1’s responsible party was notified of R1’s ongoing medication refusal prior to discontinuing R1's medications. The LPA was unable to identify a facility service plan that indicated that R1 was not taking any medications, nor that it was discussed with R1’s responsible party.

R1’s responsible party said if they had known R1 was refusing their medications, they would have intervened. While staff claimed that the facility’s physician had a phone conversation with R1’s responsible party on 8/28/2021 regarding the decision to discontinue R1’s medications, R1’s responsible party denied claims of receiving a call or voice message from the physician. There was no documentation to support claims that R1’s responsible party was either notified or consulted regarding the decision to discontinue R1’s medications. R1’s responsible party said they were only made aware of R1’s status of not taking medications when R1 was hospitalized in April 2022. It was then that the hospital staff communicated to R1's responsible party that R1 allegedly was not taking medications, per feedback received from the facility.

Based on the information obtained during the course of the investigation, there is sufficient evidence to support the claim that staff failed to notify R1’s responsible party of the change of condition. Staff said R1 had regularly refused medications upon admission to the facility and believed that R1’s responsible party was aware of this behavior. However, there is no supporting documentation to aid in claims that R1’s responsible party was notified of R1’s refusals or of the discontinuation of all medications in August 2021. In addition, R1’s responsible party denied claims that they were ever notified of the ongoing refusals, as they would have intervened if they were aware of its regular occurrence. This allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided via email for signature, along with appeal rights.