complaint·February 13, 2024

Interviews conducted with residents revealed there have not been incidents in which medication was provided by mistake. Interviews with staff revealed there was a medication error on 1/30/24 in which night shift med tech provide someone else’s medication to R1. Per med-tech (S1), staff picked up the cup at 6:00am in the morning and took the medication to R1. Upon returning to the medication room, nurse ask if the medication was provided and realized that the medication taken was not R1’s medication but R2’s medication, once S1 looked at the label in the cup. R2’s medication was a missed dosed and needed to be disposed in the morning. Per S1 it was a mistake. Facility contacted R1’s physician and responsible party. Per physician’s recommendations facility staff monitored R1 throughout the day for side effects which were reported to physician. On 2/2/24 R1 went to an office doctor visit during the visit R1 reported to have hit R1’s right shin and went out to the hospital due to the hematoma to the right shin and unrelated to the medication error. LPA observed prepared medication for residents and each cup is label with residents’ name and time. Document review revealed facility documented medication error on resident’s note and medication error report form, as well as in the medication sheet. S1 last medication training was provided on 9/25/23, 12/28/23, and 12/30/23. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Denise Sutton and a copy of this report, LIC 9099D, and appeal rights were provided.