Non-compliance follow-up·October 30, 2024

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. Administrative staff were immediately notified. Power of Attorney (POA) was also notified the same day. 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. LPA interviewed staff and Executive Director. 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, by the Regional Licensed registered nurses that conducted training on October 28, 2024. LPA has determined that further review with the Regional Manager and Licensing Program Manager needs to be followed up at a later date and time. LPA will conduct an additional case management pertaining to the incident of medication error for resident # 1(R1). Citation issued, appeal right, exit interview, and copy of report provided to ED.