Incident investigation·September 6, 2024

On 09/06/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Resident Care Coordinator RCC #1 (RCC#1) Gabby Eusebio and Assistant Administrator #1 (A#1) Ginger Enriquez. LPA explained the purpose of this visit is about an incident on 08/05/24 associated with resident #1 (R1) and staff #1 (S1) in the Arbor Hall Memory Care Unit . El Segundo Regional Office received an LIC 624 Incident Report (dated: 08/12/24). Information revealed on 08/05/24, approximately around noon, (R1) was in the dining room for lunch grabbed a Lorazepam medication from another resident sitting next to (R1), and swallowed it. On the evening of 08/05/24, (R1) had an unwitnessed fall in (R1’s) room and sustained a laceration behind the right ear. On 09/06/24, an interview with Resident Care Coordinator (RCC#1) and Assistant Administrator (A#1) verified the incident and communicated that it was the negligence of (S1) to leave medications unattended. (S1) failed to supervise and allowed for (R1) to have access to medications that were not prescribed to (R1). (RCC#1) and (A1#1) both claimed that (S1) withheld information from management and did not report the incident immediately to them. The hospice team examined (R1) and assessed the laceration after (S1) reported it to (R1's) hospice. Interviews with the CV Hospice nurse and (R1’s) authorized representatives verified the incident with the medication error may have been attributed to the unwitnessed fall with injuries. However, medication records for (R1) revealed (R1) is prescribed Lorazepam as a (PRN). Interviews were not available for (R1) and (S1). (R1) had voluntarily terminated residency on 08/31/24, and (S1) was terminated from employment. (Evaluation Report continues on LIC 809-C) Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (S1) failed to carry out the responsibilities and duties of a caregiver who failed to store medications and inaccessible to residents in care. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D. An exit interview was conducted with Ginger Enriquez, Assistant Administrator, and a hard copy of the report along with appeal rights.