Incident investigation·October 4, 2022

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit due to an incident that was reported to licensing. On 10/2/22 staff #1 (S1) gave resident #1 (R1) the wrong medication. S1 realized their error and notified the licensee and emergency services was then called along with poison control. R1 was observed and it was found that R1 did not need to be transported to the hospital due to the medication they were given was a vitamin. This same incident happened with R1 and S1 on 9/27/22 and R1 needed to be hospitalized. R1 was discharged back to the facility on 9/30/22 after being hospitalized. S1 was then given medication training along with the rest of the staff. Since this incident on 10/2/22 S1 has been terminated from their position, due to this being the second incident within the past two weeks. Immediate civil penalty of 250 dollars issued for violation of the same section within a calendar year. Deficiency cited on LIC 809 D. Appeal Rights explained. Exit interview conducted.