Incident investigation·January 11, 2024

At approximately 2:30PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection on an Incident Report that occurred on 12/15/2023 and was received by CCL on 12/21/2023. LPA met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit. Incident Report states that Resident 1s (R1s) order for routine Quetiapine was entered into the EMAR (Electronic Medication Administration Record) incorrectly by the pharmacy. The order was intended to be given as a routine medication and was entered as a PRN medication and not dispensed to resident since 11/20/2023. Per conversation with ED, the facility has a procedure for catching any errors by the pharmacy which was not followed, resulting in the medication error. ED discussed with LPA that the medication technicians could not have prevented this error as they do not have the capability of altering medication orders in the EMAR. **An immediate civil penalty in the total amount of $250.00 has been issued for a repeat violation of regulation 87465(a)(4). LIC421FC** Exit interview conducted. Copy of report, LIC-809D, LIC421FC (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.