Incident investigation·August 20, 2024

At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management in regards to an incident report submitted to the department on 08/12/2024. LPA met with Manager Katelyn Formby and reviewed records. On 08/10/2024, Resident, R1, received another residents medication. During an evening medication pass, staff gave R1 the wrong cup of medications. After R1 had already taken the pills, staff noticed it was the incorrect medication. Physician was notified and informed staff to observe resident for changes. Approximately 6 hours later, staff observed R1 to have lower than normal blood pressure and contacted emergency personnel. Resident stayed in the hospital for observation. LPA reviewed discharge paperwork and observed resident had no long term effects from the medication error. Staff was retrained on facility medication practices. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Katelyn Formby and Appeal rights were given.