Incident investigation·November 30, 2023

Licensing Program Analyst (LPA) Hansen was at facility continuing investigation into a complaint and conducted a case management for a medication error department received. LPA met with Administrator Nithi Narasappa. On 11/27/2023 Community Care Licensing (CCL) received a self-reported incident report from facility of a medication error that occurred on 11/20/2023. Resident (R1) has an as needed (PRN) prescription for Acetaminophen 500 mg. At approximately 12:45 pm R1 was inadvertently given another resident’s PRN pain medication by staff (S1). Shortly after, S1 realized error and reported to General Manager and Administrator, who notified primary care (PCP) of PRN medication not being given to R1 as prescribed by physician. Responsible party notified. R1 was monitored and had no adverse side effects from other resident’s PRN medication and remains at baseline. Report also indicates policy and procedure review was conducted with staff and an in service training on Medication Policy. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..