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32 | Based on a review of the facility forms and documents, it was learned that this facility employed a digital version of the Medication Administration Record (MAR) for all facility residents at this time. It was learned that all facility residents had their medications centrally stored and did not have immediate control of their medications at this time. A brief interview was also conducted with the facility designated Administrator, Monica Plowden, in regards to the maintenance, oversight, and auditing of this system.
Based on this interview, it was learned that facility staff were responsible to handle, dispense, and notate all of their actions within this program. It was also learned that this program required each individual staff person to log in when it came time for them to dispense the medications as prescribed.
It was learned that if a facility resident refused or did not take their prescribed medications in a timely manner, the present facility staff person would use a drop down menu, within the application, to notate that the medications were not given and should include additional notes as to the specific reason. It was observed by this LPA from the monthly medication administration records (MARs), dated from 09/16/2024 to 11/14/2024 for all (6) residents, revealed multiple times and dates where the medications were not property dispensed, not properly documented, and not properly followed up with Notes inputted within this application.
Based on interviews conducted during the course of this investigation, it was learned that there wasn't a cohesion within the core group of facility caregivers, which there were (3) main facility staff persons at this time. It was learned that on at least (1) occasion, the oncoming staff came on and discovered that the scheduled staff for the previous shift had left the facility without notification to the oncoming shift or the facility administrative team. It was learned that the facility residents had been left alone, without any facility staff care and supervision, for an unknown amount of time before the oncoming shift finally arrived to take over.
It was learned that there were notifications, in the form of phone calls and text messages, that were exchanged with the facility designated Administrator in regards to this incident.
As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegations were valid because the preponderance of the evidence standard had been met.
The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.
Appeal rights were printed and a copy was left with the facility designated representative at this time.
Exit Interview |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/15/2024
Section Cited
CCR
87411(a) | 1
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7 | Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment | 1
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7 | The facility designated representative stated that this facility was currently seeking additional staff persons for hire at this time. In addition, all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper care and supervision at all times 24 hours/7 days a |
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14 | and grounds.
This facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | week.
A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date. |
Type A
11/15/2024
Section Cited
CCR
87465(a)(4) | 1
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7 | A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
The licensee shall assist residents with self-
administered medications as needed. | 1
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7 | The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper handling, dispensing, and documentation of the resident medications. |
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14 | This facility was found to be deficient as evidenced by a review of all (6) resident medication administration records revealing that medications were not properly handled, dispensed, or notated which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | A statement of correction, along with documented proof of vendorized medication training, will be completed and submitted into CCL by the due date. |