Incident investigation·May 20, 2025

On 05/20/2024 at 02:10 PM, Licensing Program Analyst (LPA) David Doidge conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 05/06/2025. LPA met with Zinnia Koch, Director of Wellness and Assisted Living and explained the purpose of the visit. LPA collected the Physician’s Report (602) for resident listed on the Unusual Incident Report (UIR) and interviewed two (2) staff in the matter. Facility submitted a UIR to CCLD for a resident that was administered the wrong medication. S1 reported that on 05/06/2025, one of the medtech called in sick leaving them short staffed. A licensed nurse usually handles the distribution of medications. To compensate, an assisted living nurse was asked to help out. This nurse is not familiar with the residents. Medication was selected according to the Electronic Medication Administration Record (EMAR) by a medtech. It was then given to the assisted living nurse to be administered. The assisted living nurse, unfamiliar with the residents, accidentally gave the medication to the wrong resident. R1 was monitored by staff. PCP and family were notified as well as poison control. R1 showed no signs of adverse reaction. S1 conducted a one-on-one with the assisted living nurse reminding the nurse to next time be more cautious and ask questions when unsure. Steps are being taken to prevent further occurrences. Staff had in-service training. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.