Incident investigation·August 13, 2024

Licensing Program Analysts (LPAs) Trevor Byrne and Erica Mosley conducted an unannounced case management visit in regard to a self-reported incident that occurred on 08/06/2024. On that date Resident # 1 (R1) was administered the incorrect medication by Staff #1 (S1). S1 then informed the Enlivin Director (S2) of the error. R1 experienced a vomiting episode and was placed on monitoring by the resident’s physician. Between 01:14pm – 02:30pm, LPAs conducted a brief physical plant tour, interviewed staff and reviewed pertinent documentation relevant to the incident. Interviews conducted and records review revealed that community staff followed the appropriate reporting procedures and complied with the resident’s physician’s recommendations for monitoring. An in-service training was conducted on six (6) resident rights and avoiding medication errors. Three (3) staff including S2 attended the in-service. S1 at the time of the visit had terminated their employment with the facility. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.