complaint·June 6, 2023

Continued from Lic9099 It was alleged that, staff mismanaged resident’s medications, and staff over-medicated resident. Based on interviews and record review conducted, S1 confirmed with LPA that S2 mistakenly gave R1 eleven (11) types of oral medications from another resident in care on 5/28/2023. While interviewing S2, S2 confirmed with LPA that she mistakenly gave 11 types of oral medications to R1 on 5/28/2023 at approximately 8:15 AM. S1 submitted an incident report regarding medication error on 5/29/2023. LPA reviewed discharge notes for R1, which indicates that R1 had a medication overdose due to taking incorrect medication. LPA reviewed incident reports, progress notes and staff medication error statement from S2 and S3 which indicated that R1 was given the wrong medication and R1 had a medication overdose on 5/28/2023. Facility staff called 911 for further evaluation, and R1 was admitted to the hospital and returned to the facility the next day 5/29/2023, at approximately 5:30 PM. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted with RN, appeal rights given along with a copy of this report.