complaint·March 19, 2024

Staff mismanaged medication resulting in resident to be hospitalized - SUBSTANTIATED LPA reviewed an incident report that was submitted on 02/27/2024 regarding an incident that occurred on 02/22/2024. It was reported that at 8:00 pm a Medication Technician, Staff 1 (S1) reported that they gave another resident's medication to Resident 1 (R1) who was admitted to the facility that same day. EMS was called. EMS arrived, stated that R1’s vital signs were stable and R1 was transported to ER for evaluation. R1 was subsequently hospitalized for observation. No adverse effects were reported as a result of the medication error. R1 returned to community on 02/24/2024. During the course of the investigation, it was learned that when R1 was admitted to the facility their admission record did not include R1’s photograph for identification. S1 failed to follow the facility’s medication safety checks which include confirmation of resident by matching the photograph on file with the resident they are dispensing the medication to. Staff 1 stated that verifying a resident’s photograph (identifying the right person) that a medication is being dispensed is part of the “Six Rights” that the facility uses for dispensing medications. It was determined that even though there was no photograph in the resident’s file, S1 should not have dispensed the medication to R1 without confirming they were dispensing to the correct resident. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.