complaint·July 5, 2023

Regarding Allegation #1 : Staff administered wrong medication to resident in care. This complaint alleged staff gave the wrong medication to R1 . LPA Calderon conducted an interview with A1. A1 expressed that on 06/25/2023 staff was passing out medications to residents in the dining room area. A1 expressed that staff had taken medication for R1-R2 and put medication in a plastic cup. A1 expressed that staff was pulled away from medication cart due to an emergency and came back to the medication cart to finish passing out residents’ medications. A1 expressed that there was no name on the medication cups and S3 gave R1 the wrong medication. A1 expressed that R2 was given the wrong medication and R2 noticed the error by staff and R2 refused to take another residents medication. LPA Calderon conducted an interview with S1-S3. 2 out of 2 staff said that they were not working at the time of the incident but heard that staff had given the wrong medication to R1. LPA Calderon conducted an interview R2. R2 expressed that R2 was sitting at the same table as R1 when the MedTech came to their table to give them their morning medications. R2 expressed that R2 looked at the medications that were inside R2 plastic cup and R2 knew that R2 had been given the wrong medication to take. R2 expressed that staff told R1-R2 that staff was sorry for the error. On 07/05/2023 LPA Calderon obtained and reviewed incident report (dated 06/25/2023), incident report states that Med Tech gave R1 the wrong medication and was taken to the hospital due to side effects. Obtained and reviewed MAR (dated 06/25/23) for R1, which also noted error in medication on 06/25/2023. Reviewed hospital records (dated 06/25/2023) for R1 which noted accidental ingestion of nontoxic medication. On 07/05/2023 LPA Calderon had S3 take LPA Calderon through the medication process. Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation “staff administered wrong medication to resident in care” is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D. An exit interview was conducted with Administrator Linda Cardenas (A1) and a hard copy was provided by hand for records.