Incident investigation·September 15, 2021

On 9/15/2021 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Case Management Inspection in regards to an incident report received on 9/2/2021. LPA met with Administrator, Tamra Marie Tsanos. Incident report reveal that R1 was given incorrect dosage of Hydrocodone than the physician's order. Interview with S1, S2, and S3 revealed that the physician's order two different dosage for Hydrocodone with one being a PRN medication. It was discovered that PRN medication have been given incorrectly to R1. S2 stated that facility have implemented new procedures and guidelines for medication administration. Disciplinary action was given to the staff that was involved. Routine audits of medication have been implemented and staff will be provided refresher course related to medication administration. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 . Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.