Complaint·May 24, 2023

S1 conducted an emergency eye wash to R1’s eye, and once R1 felt relief, proceeded to contact R1’s Ophthalmologist who advised sending R1 to the hospital for an emergency visit. DRCS Aquino stated they submitted an incident report to the Department on 02/20/2023. Lastly, upon S1’s medication error, DRCS Aquino stated S1 did not work as a Wellness Nurse until additional job training was conducted. That same day, interview with S1, starting at 12:21 p.m. confirmed what DRCS Aquino stated. Additionally, S1 added that their shadow training was not thorough and was expedited due to a shortage in Wellness Nurses. S1 stated, once the “eye drops” were self administered, they did not panic and was able to assist R1 in rinsing their eye out. S1 stated the “eye drops” was a nasal spray. S1 proceeded to call R1’s doctor, and family representative. Lastly, S1 added that following the incident, S1 went through an intensive training for two (2) weeks where they had to shadow train with the Director of Nursing. Even though facility staff was reactive in assisting the resident when a medication error occurred, S1 stated they did not ensure that the right medication was going to be self administrated properly. Because of this, R1 was given the wrong medication solution to their right eye causing R1 irritation, burning and being sent to the hospital. Based on evidence gathered throughout the investigation, there is sufficient evidence to support the claim that staff did not ensure the correct medication was dispensed properly to resident in care. LPA Ascencio spoke with Administrator Aquino regarding timely reporting requirements and ongoing training for Wellness Nurses to prevent future medication errors. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were issued.