complaint·August 30, 2023

The department received additional information from RP and all documents, and the interviews conducted by former LPA, L. Fici, was re-reviewed by LPA, L. Hall. LPA met with and delivered the amended report. Allegation: Staff did not seek medical attention for a resident in a timely manner. The RP stated it took the staff approximately 45 minutes to contact 9-1-1 for resident (R1). Based on interviews and record review, including 2 incident reports, R1 was given the wrong medication (belonging to another resident) around 8:00am on May 28, 2023. The staff (S1) notified S4 (registered nurse) around 9:24am of the error, this was the time S1 had realized the mistake had occurred. S4 immediately conducted an assessment with R1, including taking vitals in the presence of R1’s family. The vitals were stable and R4 informed R1’s doctor via fax of the error. Around 10:15 am R1 was observed to be ‘sleepy’ and vitals were rechecked and observed to have changed. At this time, 9-1-1 call was immediately made and R1 was transported to Kaiser Hospital. R1 was discharged back to the facility on May 29, 2023. Based on record review of communication between the facility and the physician. It indicates that the facility had sent notification to the physician at 10:07am on May 28, 2023, that contained the medication that was taken and R1’s vitals that were taken when S4 was first notified. The physician replied on May 30, 2023, that R1 had been seen in the emergency department. Review of previous complaint dated June 1, 2023, control #15-AS-20230601140155, the Health Service Director (HSD) submitted a plan that will provide training in medication errors, assess the medication assistance process, and make the necessary changes to prevent errors. The Health Service Director also will enforce documentation standards for medication policy per the plan submitted to Community Care Licensing Department. Based on Interviews conducted, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . Exit interview conducted with RN, and a copy of this report provided.