complaint·May 1, 2023

Staff administered an incorrect medication to a resident. During the interview process, the administrator and resident were interviewed. Various documents were obtained and reviewed to include Admission Agreement, Medications Log, Appraisal and Needs, Incident Report, and a list of staff names. During the investigation process, it was reported that on 01/24/23 an error was made in that a medication technician accidentally gave a resident (Resident 1) another resident’s medication. Resident 1 was advised of the medication error; however, at the time, he declined to go to the hospital. Later that day, the resident stated that he “Didn’t feel right” and he agreed to go to the hospital. The resident was monitored and returned to the facility later in the evening. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Facility staff did not notify a resident’s responsible party of an incident . During the interview process, the administrator and resident were interviewed. Various documents were obtained and reviewed to include Admission Agreement, Medications Log, Appraisal and Needs, Incident Report, and a list of staff names. During the investigation process, it was reported that on 01/24/23 in the morning, an error was made in that a medication technician accidentally gave a resident (Resident 1) another resident’s medication. Resident 1 was advised of the medication error; however, at the time, he declined to go to the hospital. continued It was reported that the resident’s family was notified of the medication error in the morning; however, the family was not advised that hospital services were offered to the resident and that he declined. During the late afternoon, the family contacted the resident and indicated that the resident was “Not himself.” It was reported that the medication technician was to contact the family to advise of the status of the resident; however, the medication technician did not. Towards the evening, the resident was taken to the hospital, was monitored and later returned to the facility when he was feeling stronger and more alert. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated . California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date; civil penalties may be assessed.