Incident investigation·April 25, 2024

On 4/25/2024 at 1:30 PM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a Case Management visit in regards to an unusual incident report received 3/21/2024. LPA met with Executive Director, Teresa Truong and explained the purpose of the visit. CCLD received an unusual incident report dated 3/21/2024 That stated that on 3/17/2024, at approximately 3:00pm and 8:00 pm, R1 was given the wrong dose of medication. On 3/18/2024, Medtech noticed the medication error and notified the Area nurse Manager. R1 was given 8 mg of Ativan at 3:00 pm and 8:00 pm. R1 order is Ativan 2mg: take 2 tablets by mouth three times a day. Physician and responsible parties were notified. LPA spoke with Executive Director who stated that when the medication was renewed the milligrams per tablet went up and the Medtech(S1) did not notice. When giving R1 their medications they gave them the usual amount of tablets not noticing that because of the milligram increase they should have given less tablets. Executive Director acknowledged that it was an oversight and spoke with staff about the importance of paying attention to detail. A training was provided on Medication Procedures and Documentation on 3/20/2024. Medtech(S1) who gave the wrong dosage of medication was written up. Resident sustained no ill side effects. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.