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32 | Facility not dispensing medication as prescribed.
During the investigative process, four staff persons and the regional center coordinator were interviewed. Several other staff persons were contacted for an interview; however, they either did not return the telephone call or had resigned from working at the facility. The resident (Resident 1) was not interviewed, as she had since passed away. A walk-through of the facility was conducted whereas residents’ well-being was observed, and several records were reviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Appraisal and Needs, Medication Administration Records (MARs), staff training records, list of staff names and a list of resident names.
On 08/29/22 an audit of the resident’s (Resident 1) medications was conducted by LPA Gurriere. During the audit, it was noted on “yellow sticky notes” that the staff were to discontinue medications. On 08/10/22, the facility’s nurse practitioner had advised the staff to discontinue several medications which included Buspirone, 10mg; Lamotrigine, 25mg; and Trazodone, 50mg. On 08/12/22 additional medications changed, which included to discontinue Morphine .25ml every four hours but a new order on a sticky note indicated to increase Morphine .25ml every two hours. The staff were advised that per the regulations, for every change that is made by the physician there shall be a written prescription order. A written prescription order was not in place to discontinue or increase the dosage of medications.
Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.
Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
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