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25 | Licensing Program Analyst (LPA) Hansen arrived unannounced and is conducting a Case Management visit because of deficiencies that were observed during a Complaint Investigation.
Licensing Program Analyst (LPA) Hansen observed facility uses Medication Administration Records (MARS) to document medication records. Facility uses a MAR which documents each medication dose that a resident is given by staff initializing the field when medication is given. Per file review, three residents were noted to have fields missing that may indicate a missed medication. LPA conducted interviews with S1 and S3 to confirm use of MARS and procedure if a resident refuses medication. Based on investigation the facility failed to always complete all MARS refusals and did not note reason for medications not being administered, including but not limited to resident refusals. Deficiencies cited Resident Records 87506(a) See LIC809-D.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
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