286803675-6-25-2021-21-AS-BMOS-C4VRC6-20210713125345

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803675
Report Date: 06/24/2021
Date Signed: 06/25/2021 08:52:30 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2021 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210126093702

FACILITY NAME:	ASSISTED LIVING OF NAPA VALLEY-HAMILTON		FACILITY NUMBER:	286803675
ADMINISTRATOR:	SMITH, KRYSTAL		FACILITY TYPE:	740
ADDRESS:	3100 HAMILTON STREET		TELEPHONE:	(707) 637-4562
CITY:	NAPA	STATE: CA	ZIP CODE:	94559
CAPACITY:	9	CENSUS: 6	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Chrissy Arnke/Krystal Smith		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff over medicated resident resulting in hospitalization
Unqualified staff administered injectable medications to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott made contact this date, with Chrissy Arnke, Administrator and Krystal Smith, Licensee via Facetime for the purpose of delivering findings for above allegations.

There is an allegation staff over medicated resident resulting in hospitalization. Incident report dated 10/15/2020 reflects Administrator received a phone call from residents physician letting facility know resident had an abnormal lab result requiring evaluation in the Emergency Room and possible hospitalization. Report also reflects under Medical Treatment Necessary -hospitalization for critical lab abnormalities. This report was received by CCL on 6/11/2021 outside of regulatory time frames. This will be addressed in a case management.

During the complaint investigation LPA reviewed medication records for R1, including centrally stored records and administration records. Per e-mail from Administrator on 5/21/2021 prior to hospitalization R1’s INR (international normalized ratio) blood levels were checked by the Kaiser Coumadin clinic.
(See LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210126093702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ASSISTED LIVING OF NAPA VALLEY-HAMILTON	FACILITY NUMBER: 286803675
	VISIT DATE: 06/24/2021

NARRATIVE

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There is an allegation unqualified staff administered injectable medications to resident. Staff interviewed described the various methods they use to assist resident with medications, including liquid medications from syringes. Administrator requires staff to take a medication quiz to confirm completion of medication training module. One of the questions on the quiz reflects, ”Which of the following should you do before assisting the resident with their medications.” Based on a review of staff training records, all staff who assist in the administration of medications have the required training per regulation. Based on LPA interviews, record review and observation although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210126093702

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ASSISTED LIVING OF NAPA VALLEY-HAMILTON	FACILITY NUMBER: 286803675
	VISIT DATE: 06/24/2021

NARRATIVE

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LPA obtained information regarding procedures of Coumadin Clinic at facility. The clinic would call the facility when they received the results and tell S1 or S2 over the phone what dosage instructions to follow prior to the next blood draw. The staff would write it on a post it note and set up the medication according to those directions. R1 would receive Coumadin dosage based on those directions until the next time the Coumadin Clinic would draw labs. The standing MD order and instructions on the medication bottle only stated "Coumadin 5mg- take as directed. Documentation revealed facility did not keep record of weekly dosage of Coumadin per physician/nurse advising after blood draw results reviewed. There is no evidence R1 had access to medications or medication was missing. This will be addressed in a case management.
LPA attempted to contact treating physician for 10/15/2020 hospitalization on 4/5/2021, 4/13/2021, 4/28/2021, 5/26/2021 and 6/19/2021 to distinguish if cause of hospitalization was the result of overmedicating R1 or an accumulation of Coumadin in R1’s system.

Medication Administrator Records (MARs) for October 2020 reflect Warfarin (Coumadin) 5mg take as directed. Kaiser Medication list indicates Warfarin (Coumadin) 5 mg oral tab Take as directed by Coumadin Clinic or physician. Order was effective as of 4/2/2020. Hospitalization documentation dated 10/15/2020 reflects a diagnosis of Anticoagulant Overdose, Accidental, init ICD-10-CM T45.511A. Documentation also reflects reason for transfusion -urgent reversal of Warfarin. Interview with outside party on 6/23/2021 indicated…in general it would be very difficult to determine from labs whether high lab values are due to an excessive dose of Coumadin versus accumulation. LPA asked about ICD 10 code. Outside party indicated the word "overdose" is not a term used in the medical field, it is a reference code. There are so many different contributing factors that affect lab values…LPA attempted to interview R1’s Primary Care Physician on 4/26/2021. Physician refused to give LPA any information regarding R1. Based on LPA interviews, record review and observation although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

(See LIC 9099-C)

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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