Incident investigation·January 7, 2025

On 1/7/2025 at 2:00pm, Licensing Program Analysts (LPAs) Frank and Felias arrived unannounced to conduct a Case Management inspection and met with Executive Director, Lauren Cottman and Resident Care Director, Parinda Kleinberg. The facility submitted an Incident Report (IR) for Resident 1 (R1) for a medication error. The IR stated that on Sunday 12/8/2024 Resident Care Director reviewed medications orders and found new orders from the resident's doctor. The new orders received stated that facility was to stop one medication and start a new medication once it was received by the facility. The med tech on duty (S1) faxed orders to the pharmacy the same day but gave both medications to the resident on the 12/6/24 and 12/7/24 PM shifts. Resident Care Director faxed details of the incident to R1's primary physician and notified the resident's responsible party. LPAs reviewed documentation. Correspondence between facility and R1's primary care physician showed that R1's new medication was not sent by the pharmacy until 12/6/24. Facility received the new medication on 12/8/24. R1's Medication Administration Records (MAR) shows that R1's old medication was given on 12/6/24, 12/7/24, and the morning of 12/8/24. R1's new medication arrived the evening of 12/8/24. Review of R1's MAR showed that when the new medication arrived to the facility, the old medication was discontinued and the new medication was administered appropriately. Review of records showed that there was no overlap in medications. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of document.