Incident investigation·April 7, 2023

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit in regards to an SIR (Special Incident Report) that was submitted pertaining to resident #1 (R1) who was administered wrong medication. LPA met with Executive Director Myla Belson, who was informed the reason of the visit, and who reported to LPA, that staff # 1 (S1) accidentally administered the wrong medication to R1 because there was another resident with the same first name but different last name. S1 immediately contacted the Health Services Director, ED, and Memory Care Director. Family was also notified the same day; who was visiting R1 at the facility. R1 was sent to the hospital for evaluation, and was returned to the community, with no documentation of any medical or adverse action of the wrong medication. The ED reported the incident to Licensing with a SIR. During today's visit. ED reported that the facility and corporate implemented additional medication training, that involves licensed registered nurses that will be conducting training on April 11 and 13, 2023. Also, ED reported that additional medication training was conducted with the Regional Health Services Specialist, who is a licensed LVN (Licensed Vocational Nurse). There responsibilities is to oversee and provide additional support and resources to facility and staff. In addition, medication procedures were changed, to resident's identification are now labeled by last name and first initial,room number, and a picture of the resident. ED has recently hired a newly Wellness Nurse, that is currently in training, that would be available for additional medication and facility support. ED will continue ensure medication technicians receive adequate and complete training, that involves shadowing by Health Services Director, Wellness Nurse, or Resident Care Coordinator. ED will also continue to follow the training plan that was submitted previously for the plan of correction (POC). ED was made aware that during today's visit a citation and repeat civil penalty will be issued due to the recent incident involving medication error. Exit interview, appeal rights, citation and civil penalty issued to ED and copy of the report.