During the investigation of complaint 29-AS-20240515122500, it was alleged that Resident 1 (R1) did not receive their eyedrops as prescribed. Staff interviewed indicated R1 sometimes refused their eyedrops. LPA reviewed Medication Administration Records (MARs) for R1 from September 2023 to March 2024. LPA observed different reasons documented for resident not receiving medications. For eyedrops specifically, LPA observed several dates where R1 did not receive their eyedrops as prescribed, and reasons included “resident very sleepy,” “resident refused,” “physically unable to take – resident very sleepy,” “physically unable to take – resident in a deep sleep.”

LPA asked for documentation showing that the prescription eyedrop refusals were communicated to R1’s physician. LPA was provided only two documented cases where R1’s physician was notified of refused eye drops, on 4/18/2023 and 10/30/2022. The refusals also included other medications, and the refusal notice was sent to R1’s primary care physician, where they notated “thank you, no new orders.” Regulations require that any changes in the resident are documented and brought to the attention of the “resident’s physician.” The facility only notified R1’s primary care physician of two cases where the resident refused the medication, due to agitation per interviews. The facility did not notify R1’s physician when R1 did not take their medications due to being asleep, which occurred more times. Although the regulation does not specify which physician the changes should be brought to, Technical Assistance is provided to the facility to recommend that relevant specialists and prescribing physicians should also be notified of changes including medications not given, in addition to primary care physician’s.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties.