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32 | Resident Caregiver Notes indicated that responsible party and MD were notified of medication error made on 4/6/2020 but did not indicate that CCLD was notified. The Resident Caregiver Notes also indicated that R1 did not have any adverse effects noted at the time and continued to be stable after the medication error.
R1’s MAR for May of 2020 indicated R1 had refused routine medications throughout the month, including a sertraline refusal on 5/1/2020. R1’s MAR for May of 2020 did not indicate whether a hospice nurse or an MD were notified of R1’s medication refusals. On 8/12/2020, LPA requested Administrator send CCLD all fax confirmations indicating that a physician was notified of R1’s medication refusals for the month of May, 2020. As of to date, no fax confirmations were given to LPA regarding several of R1’s routine medication refusals for May 2020, including sertraline refusal on 5/1/2020. Also, as of to date, no notes were provided on R1’s MAR for May of 2020 indicating what was done by the facility after resident refused medication, including sertraline refusal on 5/1/2020.
LPA reviewed and obtained the facility’s plan of operation, which indicates the facility’s Medication Refusal policy. The Medication Refusal policy states “Each time a resident refuses a medication, it must be reported to his/her physician in writing via fax and to the family via a phone call.” It also states: “It must be documented on the back of the MAR with an explanation of why the resident will not take the medication and what you did to try to get the resident to take the medication.”
Based on interviews conducted by LPA and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D.
Exit interview was conducted and appeal rights addressed with Administrator via telephone and a copy of this report and appeal rights will be provided to the facility via email. This facility shall sign and return a copy of the report to CCLD and print a copy to be retained by the facility. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/10/2020
Section Cited
CCR
87465(a)(5) | 1
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7 | 87465 Incidental Medical and Dental Care(a) A plan for incidental medical..care shall be developed by each facility. The plan shall encourage routine medical...and provide for assistance in obtaining such care, by compliance with the following: (5) The licensee shall assist residents with self-administered medications as needed. | 1
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7 | The facility shall notify the primary care physician and responsible party when a resident refuses medication. The Administrator agrees to conduct a training with medication technicians regarding the reporting requirements when medications are refused by residents. |
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14 | This requirement is not met as evidenced by: Based on LPA’s observation of records, R1 refused medication on multiple occasions on month of May, 2020. R1’s primary care physician and responsible party were not notified of the refusal of medication. R1 was also given another resident's medication, which posed an immediate risk to resident in care.
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14 | The administrator agrees to also conduct a training with all medication technicians regarding medication errors.
Administrator shall submit proof of training along with signatures of staff that participated in the training to LPA by the POC due date of 11/11/2020. |
Type B
11/17/2020
Section Cited
CCR
87211(a)(1)(D) | 1
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7 | 87211 Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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7 | The Administrator agrees to conduct a training with all staff regarding the reporting requirements. Administrator shall submit proof of training along with signatures of staff that participated in the training to LPA by POC due date of 11/17/2020. |
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14 | This requirement is not met as evidenced by:
The facility did not submit a written report to CCLD when R1 received another resident's medication in error, which poses a potential risk to resident in care. | 8
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